Current Psychiatry

Like all physicians, psychiatrists practice in an increasingly complex health care environment, with escalating demands for productivity, rising threats of malpractice, expanding clinical oversight, and growing concerns about income. Additionally, psychiatric practice presents its own challenges, including limited resources and concerns about patient violence and suicide. These concerns can make it difficult to establish a healthy work–life balance.

Physicians, including psychiatrists, are at risk for alcohol or substance abuse/dependency, burnout, and suicide. As psychiatrists, we need to attend to our own personal and professional health so that we can best help our patients. This review focuses on the challenges psychiatrists face that can adversely affect their well-being and offers strategies to reduce the risk of burnout and enhance wellness.

The challenges of medicine and their impact on psychiatrists

The practice of medicine is inherently challenging. It requires hard work, discipline, dedication, and faithfulness to high ethical standards. Additional challenges include declining autonomy and opportunities for social support, increasing accountability, and a growing interest in reducing the cost of care by employing more non-physician health professionals—which in psychiatry typically include psychologists, nurse practitioners, and social workers. The uncertainty of the Affordable Care Act, declining income, and concerns about the nature of future medical practice are also stressors.^1,2

Factors that contribute to psychiatrists’ stress include:

• limited resources
• concerns about patient violence and suicide
• crowded inpatient units
• changing culture in mental health services
• high work demands
• poorly defined roles of consultants
• declining authority
• frustration with the inability to impact systemic change
• conflict between responsibility toward employers vs the patient
• isolation.³

Concern about patient suicide is a significant stressor.^4,5 Some evidence suggests that the impact of a patient’s suicide on a physician is more severe when it occurs during training than after graduation and is inversely correlated with the clinician’s perceived social integration into their professional network.⁵

Impediments to a physician’s well-being

Alcohol abuse/dependence. Approximately 13% of male physicians and 21% of female physicians meet Alcohol Use Disorders Identification Test Version C criteria for alcohol abuse or dependence, according to a study of approximately 7,300 U.S. physicians from all specialties.⁶ (In this study, prescription drug abuse and use of illicit drugs were rare.) Age, hours worked, male sex, being married or partnered, having children, and being in a specialty other than internal medicine were independently associated with alcohol abuse or dependence.

Fortunately, psychiatrists were among the specialties with below average likelihood to meet diagnostic criteria for alcohol abuse/dependency.⁶ However, alcohol abuse or dependency was associated with burnout, depression, suicidal ideation, lower quality of life, lower career satisfaction, and medical errors.

Burnout is a long-term stress reaction consisting of:

• physical and emotional exhaustion (feeling depleted)
• depersonalization (cynicism, lack of engagement with or negative attitudes toward patients)
• reduced sense of personal accomplishment (lack of a sense of purpose).⁷

In a 2017 survey of >14,000 U.S. physicians from 27 specialties, 42% of psychiatrists reported burnout.⁸ In another survey of approximately 300 resident physicians across all specialties in a tertiary academic hospital, 69% met criteria for burnout.⁹ This condition affects resident physicians as well as those in practice. Residents and program directors cited a lack of work–life balance and feeling unappreciated as factors contributing to burnout.

Among physicians, factors that contribute to burnout include loss of autonomy, diminished status as physicians, and increased work pressures. Burnout has a negative impact on both patients and health care systems. It is associated with an increased risk of depression and can contribute to:

• broken relationships
• alcohol abuse
• physician suicide
• decreased quality of care, including patient safety and satisfaction
• increased risk of malpractice suits
• reduced patient adherence to medical recommendations.^5,10-12

Physicians who embrace medicine as a calling (ie, committing one’s life to personally meaningful work that serves a prosocial purpose) experience less burnout. According to a survey of approximately 900 primary care physicians and 300 psychiatrists, 42% of psychiatrists strongly agreed that medicine is a calling.¹³ Overall, physicians with a high sense of calling reported less burnout than those with a lower sense of calling (17% vs 31%, respectively).¹³

Depression and suicide. Gold et al¹² analyzed a database that included information on approximately 31,600 adult suicide victims, and 203 of these victims were physicians. Compared with others, physicians were more likely to have a diagnosed mental illness or an occupation-related problem that contributed to suicide. Toxicology results also showed that physician suicide victims were significantly more likely than non-physician victims to test positive for benzodiazepines and barbiturates, but not antidepressants, which suggests that physicians with depression may not have been receiving adequate treatment.¹²

Although occupation-related stress and inadequate mental health treatment may be modifiable risk factors to reduce suicide deaths among physicians, stigma and fear of medical staff and licensure issues may deter physicians from seeking treatment.¹⁴

Steps to avoid burnout

Evidence-based interventions. There is limited evidence-based data regarding specific interventions for preventing burnout and reducing stress among physicians, particularly among psychiatrists.⁴

A randomized controlled trial of 74 practicing physicians at the Mayo Clinic in Rochester, Minnesota, evaluated the effectiveness of 19 biweekly physician-facilitated discussion groups.¹⁵ The groups covered topics such as elements of mindfulness, reflection, shared experience, and small-group learning. The institution provided 1 hour of paid time every other week for physicians to participate in this program. Physicians in the control group could schedule and use this time as they chose. Researchers also collected data on 350 non-trial participants.

The proportion of participants who strongly agreed that their work was meaningful increased 6.3% in the intervention group but decreased 6.3% in the control group and 13.4% among non-trial participants (P = .04).¹⁵ Rates of depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention group, decreased slightly in the control group, and increased in the non-trial cohort. Results were sustained at 12 months after the study. There were no statistically significant differences in stress, symptoms of depression, overall quality of life, or job satisfaction.¹⁵

Preliminary evidence suggests that residents and fellows would find a wellness or suicide prevention program helpful. One study found that the use of one such program, which provided individual counseling, psychiatric evaluation, and wellness workshops for residents, fellows, and faculty in an academic health center, increased from 5% to 25% of eligible participants, and participants reported high levels of satisfaction with the program.¹⁶ Such programs would require institutional support for space and clinical staff.¹⁵

Empathy. As psychiatrists, we are taught to be empathetic. Yet, with the numerous challenges we face, it is not always easy. Stressors such as an increased workload or burnout can adversely affect a psychiatrist’s ability to provide empathetic care.¹⁷ However, empathetic treatment has clear benefits for both physicians and patients. Empathic skills can lead to more professional satisfaction and outcomes, which are important components of accountability, and can:

• promote patient satisfaction
• establish trust
• reduce anxiety
• increase adherence to treatment regimens
• improve health outcomes
• decrease the likelihood of malpractice suits.¹⁷

Mindfulness is a “flexible state of mind in which we are actively engaged in the present, noticing new things and sensitive to context.”^18,19 It may sound mundane to cling to phrases such as “living in the present,” but mindfulness can be a valuable tool for psychiatrists who struggle to maintain well-being in medicine’s challenging milieu. The process of mindfulness—actively drawing distinctions and noticing new things, “seeing the familiar in the novel and the novel in the familiar”—can ensure that we have active minds, that we are involved, and that we are capturing the joy of living in the stimulating present.¹⁸

Focus on issues you can control

Many of the factors that negatively influence professional satisfaction and well-being, such as loss of autonomy, demand for increased patient care volume, and increasing scrutiny on the quality of care, are beyond a psychiatrist’s control. Medical administrators can help reduce some of these issues by increasing physician autonomy, offering physicians the opportunity to work part-time, offering medical staff workshops to enhance positive communication, or addressing leader­ship problems. However, psychiatrists may benefit most by identifying modifiable issues under their own control, such as prioritizing a work–life balance, applying the fundamentals of a health prevention strategy to their own lives (Box^20,21), approaching medicine as a calling, embracing an empathetic approach to patient care, and bringing mindfulness to medical practice.

Like all physicians, psychiatrists practice in an increasingly complex health care environment, with escalating demands for productivity, rising threats of malpractice, expanding clinical oversight, and growing concerns about income. Additionally, psychiatric practice presents its own challenges, including limited resources and concerns about patient violence and suicide. These concerns can make it difficult to establish a healthy work–life balance.

Physicians, including psychiatrists, are at risk for alcohol or substance abuse/dependency, burnout, and suicide. As psychiatrists, we need to attend to our own personal and professional health so that we can best help our patients. This review focuses on the challenges psychiatrists face that can adversely affect their well-being and offers strategies to reduce the risk of burnout and enhance wellness.

The challenges of medicine and their impact on psychiatrists

The practice of medicine is inherently challenging. It requires hard work, discipline, dedication, and faithfulness to high ethical standards. Additional challenges include declining autonomy and opportunities for social support, increasing accountability, and a growing interest in reducing the cost of care by employing more non-physician health professionals—which in psychiatry typically include psychologists, nurse practitioners, and social workers. The uncertainty of the Affordable Care Act, declining income, and concerns about the nature of future medical practice are also stressors.^1,2

Factors that contribute to psychiatrists’ stress include:

• limited resources
• concerns about patient violence and suicide
• crowded inpatient units
• changing culture in mental health services
• high work demands
• poorly defined roles of consultants
• declining authority
• frustration with the inability to impact systemic change
• conflict between responsibility toward employers vs the patient
• isolation.³

Concern about patient suicide is a significant stressor.^4,5 Some evidence suggests that the impact of a patient’s suicide on a physician is more severe when it occurs during training than after graduation and is inversely correlated with the clinician’s perceived social integration into their professional network.⁵

Impediments to a physician’s well-being

Alcohol abuse/dependence. Approximately 13% of male physicians and 21% of female physicians meet Alcohol Use Disorders Identification Test Version C criteria for alcohol abuse or dependence, according to a study of approximately 7,300 U.S. physicians from all specialties.⁶ (In this study, prescription drug abuse and use of illicit drugs were rare.) Age, hours worked, male sex, being married or partnered, having children, and being in a specialty other than internal medicine were independently associated with alcohol abuse or dependence.

Fortunately, psychiatrists were among the specialties with below average likelihood to meet diagnostic criteria for alcohol abuse/dependency.⁶ However, alcohol abuse or dependency was associated with burnout, depression, suicidal ideation, lower quality of life, lower career satisfaction, and medical errors.

Burnout is a long-term stress reaction consisting of:

• physical and emotional exhaustion (feeling depleted)
• depersonalization (cynicism, lack of engagement with or negative attitudes toward patients)
• reduced sense of personal accomplishment (lack of a sense of purpose).⁷

In a 2017 survey of >14,000 U.S. physicians from 27 specialties, 42% of psychiatrists reported burnout.⁸ In another survey of approximately 300 resident physicians across all specialties in a tertiary academic hospital, 69% met criteria for burnout.⁹ This condition affects resident physicians as well as those in practice. Residents and program directors cited a lack of work–life balance and feeling unappreciated as factors contributing to burnout.

Among physicians, factors that contribute to burnout include loss of autonomy, diminished status as physicians, and increased work pressures. Burnout has a negative impact on both patients and health care systems. It is associated with an increased risk of depression and can contribute to:

• broken relationships
• alcohol abuse
• physician suicide
• decreased quality of care, including patient safety and satisfaction
• increased risk of malpractice suits
• reduced patient adherence to medical recommendations.^5,10-12

Physicians who embrace medicine as a calling (ie, committing one’s life to personally meaningful work that serves a prosocial purpose) experience less burnout. According to a survey of approximately 900 primary care physicians and 300 psychiatrists, 42% of psychiatrists strongly agreed that medicine is a calling.¹³ Overall, physicians with a high sense of calling reported less burnout than those with a lower sense of calling (17% vs 31%, respectively).¹³

Depression and suicide. Gold et al¹² analyzed a database that included information on approximately 31,600 adult suicide victims, and 203 of these victims were physicians. Compared with others, physicians were more likely to have a diagnosed mental illness or an occupation-related problem that contributed to suicide. Toxicology results also showed that physician suicide victims were significantly more likely than non-physician victims to test positive for benzodiazepines and barbiturates, but not antidepressants, which suggests that physicians with depression may not have been receiving adequate treatment.¹²

Although occupation-related stress and inadequate mental health treatment may be modifiable risk factors to reduce suicide deaths among physicians, stigma and fear of medical staff and licensure issues may deter physicians from seeking treatment.¹⁴

Steps to avoid burnout

Evidence-based interventions. There is limited evidence-based data regarding specific interventions for preventing burnout and reducing stress among physicians, particularly among psychiatrists.⁴

A randomized controlled trial of 74 practicing physicians at the Mayo Clinic in Rochester, Minnesota, evaluated the effectiveness of 19 biweekly physician-facilitated discussion groups.¹⁵ The groups covered topics such as elements of mindfulness, reflection, shared experience, and small-group learning. The institution provided 1 hour of paid time every other week for physicians to participate in this program. Physicians in the control group could schedule and use this time as they chose. Researchers also collected data on 350 non-trial participants.

The proportion of participants who strongly agreed that their work was meaningful increased 6.3% in the intervention group but decreased 6.3% in the control group and 13.4% among non-trial participants (P = .04).¹⁵ Rates of depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention group, decreased slightly in the control group, and increased in the non-trial cohort. Results were sustained at 12 months after the study. There were no statistically significant differences in stress, symptoms of depression, overall quality of life, or job satisfaction.¹⁵

Preliminary evidence suggests that residents and fellows would find a wellness or suicide prevention program helpful. One study found that the use of one such program, which provided individual counseling, psychiatric evaluation, and wellness workshops for residents, fellows, and faculty in an academic health center, increased from 5% to 25% of eligible participants, and participants reported high levels of satisfaction with the program.¹⁶ Such programs would require institutional support for space and clinical staff.¹⁵

Empathy. As psychiatrists, we are taught to be empathetic. Yet, with the numerous challenges we face, it is not always easy. Stressors such as an increased workload or burnout can adversely affect a psychiatrist’s ability to provide empathetic care.¹⁷ However, empathetic treatment has clear benefits for both physicians and patients. Empathic skills can lead to more professional satisfaction and outcomes, which are important components of accountability, and can:

• promote patient satisfaction
• establish trust
• reduce anxiety
• increase adherence to treatment regimens
• improve health outcomes
• decrease the likelihood of malpractice suits.¹⁷

Mindfulness is a “flexible state of mind in which we are actively engaged in the present, noticing new things and sensitive to context.”^18,19 It may sound mundane to cling to phrases such as “living in the present,” but mindfulness can be a valuable tool for psychiatrists who struggle to maintain well-being in medicine’s challenging milieu. The process of mindfulness—actively drawing distinctions and noticing new things, “seeing the familiar in the novel and the novel in the familiar”—can ensure that we have active minds, that we are involved, and that we are capturing the joy of living in the stimulating present.¹⁸

Focus on issues you can control

Many of the factors that negatively influence professional satisfaction and well-being, such as loss of autonomy, demand for increased patient care volume, and increasing scrutiny on the quality of care, are beyond a psychiatrist’s control. Medical administrators can help reduce some of these issues by increasing physician autonomy, offering physicians the opportunity to work part-time, offering medical staff workshops to enhance positive communication, or addressing leader­ship problems. However, psychiatrists may benefit most by identifying modifiable issues under their own control, such as prioritizing a work–life balance, applying the fundamentals of a health prevention strategy to their own lives (Box^20,21), approaching medicine as a calling, embracing an empathetic approach to patient care, and bringing mindfulness to medical practice.

Like all physicians, psychiatrists practice in an increasingly complex health care environment, with escalating demands for productivity, rising threats of malpractice, expanding clinical oversight, and growing concerns about income. Additionally, psychiatric practice presents its own challenges, including limited resources and concerns about patient violence and suicide. These concerns can make it difficult to establish a healthy work–life balance.

Physicians, including psychiatrists, are at risk for alcohol or substance abuse/dependency, burnout, and suicide. As psychiatrists, we need to attend to our own personal and professional health so that we can best help our patients. This review focuses on the challenges psychiatrists face that can adversely affect their well-being and offers strategies to reduce the risk of burnout and enhance wellness.

The challenges of medicine and their impact on psychiatrists

The practice of medicine is inherently challenging. It requires hard work, discipline, dedication, and faithfulness to high ethical standards. Additional challenges include declining autonomy and opportunities for social support, increasing accountability, and a growing interest in reducing the cost of care by employing more non-physician health professionals—which in psychiatry typically include psychologists, nurse practitioners, and social workers. The uncertainty of the Affordable Care Act, declining income, and concerns about the nature of future medical practice are also stressors.^1,2

Factors that contribute to psychiatrists’ stress include:

• limited resources
• concerns about patient violence and suicide
• crowded inpatient units
• changing culture in mental health services
• high work demands
• poorly defined roles of consultants
• declining authority
• frustration with the inability to impact systemic change
• conflict between responsibility toward employers vs the patient
• isolation.³

Concern about patient suicide is a significant stressor.^4,5 Some evidence suggests that the impact of a patient’s suicide on a physician is more severe when it occurs during training than after graduation and is inversely correlated with the clinician’s perceived social integration into their professional network.⁵

Impediments to a physician’s well-being

Alcohol abuse/dependence. Approximately 13% of male physicians and 21% of female physicians meet Alcohol Use Disorders Identification Test Version C criteria for alcohol abuse or dependence, according to a study of approximately 7,300 U.S. physicians from all specialties.⁶ (In this study, prescription drug abuse and use of illicit drugs were rare.) Age, hours worked, male sex, being married or partnered, having children, and being in a specialty other than internal medicine were independently associated with alcohol abuse or dependence.

Fortunately, psychiatrists were among the specialties with below average likelihood to meet diagnostic criteria for alcohol abuse/dependency.⁶ However, alcohol abuse or dependency was associated with burnout, depression, suicidal ideation, lower quality of life, lower career satisfaction, and medical errors.

Burnout is a long-term stress reaction consisting of:

• physical and emotional exhaustion (feeling depleted)
• depersonalization (cynicism, lack of engagement with or negative attitudes toward patients)
• reduced sense of personal accomplishment (lack of a sense of purpose).⁷

In a 2017 survey of >14,000 U.S. physicians from 27 specialties, 42% of psychiatrists reported burnout.⁸ In another survey of approximately 300 resident physicians across all specialties in a tertiary academic hospital, 69% met criteria for burnout.⁹ This condition affects resident physicians as well as those in practice. Residents and program directors cited a lack of work–life balance and feeling unappreciated as factors contributing to burnout.

Among physicians, factors that contribute to burnout include loss of autonomy, diminished status as physicians, and increased work pressures. Burnout has a negative impact on both patients and health care systems. It is associated with an increased risk of depression and can contribute to:

• broken relationships
• alcohol abuse
• physician suicide
• decreased quality of care, including patient safety and satisfaction
• increased risk of malpractice suits
• reduced patient adherence to medical recommendations.^5,10-12

Physicians who embrace medicine as a calling (ie, committing one’s life to personally meaningful work that serves a prosocial purpose) experience less burnout. According to a survey of approximately 900 primary care physicians and 300 psychiatrists, 42% of psychiatrists strongly agreed that medicine is a calling.¹³ Overall, physicians with a high sense of calling reported less burnout than those with a lower sense of calling (17% vs 31%, respectively).¹³

Depression and suicide. Gold et al¹² analyzed a database that included information on approximately 31,600 adult suicide victims, and 203 of these victims were physicians. Compared with others, physicians were more likely to have a diagnosed mental illness or an occupation-related problem that contributed to suicide. Toxicology results also showed that physician suicide victims were significantly more likely than non-physician victims to test positive for benzodiazepines and barbiturates, but not antidepressants, which suggests that physicians with depression may not have been receiving adequate treatment.¹²

Although occupation-related stress and inadequate mental health treatment may be modifiable risk factors to reduce suicide deaths among physicians, stigma and fear of medical staff and licensure issues may deter physicians from seeking treatment.¹⁴

Steps to avoid burnout

Evidence-based interventions. There is limited evidence-based data regarding specific interventions for preventing burnout and reducing stress among physicians, particularly among psychiatrists.⁴

A randomized controlled trial of 74 practicing physicians at the Mayo Clinic in Rochester, Minnesota, evaluated the effectiveness of 19 biweekly physician-facilitated discussion groups.¹⁵ The groups covered topics such as elements of mindfulness, reflection, shared experience, and small-group learning. The institution provided 1 hour of paid time every other week for physicians to participate in this program. Physicians in the control group could schedule and use this time as they chose. Researchers also collected data on 350 non-trial participants.

The proportion of participants who strongly agreed that their work was meaningful increased 6.3% in the intervention group but decreased 6.3% in the control group and 13.4% among non-trial participants (P = .04).¹⁵ Rates of depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention group, decreased slightly in the control group, and increased in the non-trial cohort. Results were sustained at 12 months after the study. There were no statistically significant differences in stress, symptoms of depression, overall quality of life, or job satisfaction.¹⁵

Preliminary evidence suggests that residents and fellows would find a wellness or suicide prevention program helpful. One study found that the use of one such program, which provided individual counseling, psychiatric evaluation, and wellness workshops for residents, fellows, and faculty in an academic health center, increased from 5% to 25% of eligible participants, and participants reported high levels of satisfaction with the program.¹⁶ Such programs would require institutional support for space and clinical staff.¹⁵

Empathy. As psychiatrists, we are taught to be empathetic. Yet, with the numerous challenges we face, it is not always easy. Stressors such as an increased workload or burnout can adversely affect a psychiatrist’s ability to provide empathetic care.¹⁷ However, empathetic treatment has clear benefits for both physicians and patients. Empathic skills can lead to more professional satisfaction and outcomes, which are important components of accountability, and can:

• promote patient satisfaction
• establish trust
• reduce anxiety
• increase adherence to treatment regimens
• improve health outcomes
• decrease the likelihood of malpractice suits.¹⁷

Mindfulness is a “flexible state of mind in which we are actively engaged in the present, noticing new things and sensitive to context.”^18,19 It may sound mundane to cling to phrases such as “living in the present,” but mindfulness can be a valuable tool for psychiatrists who struggle to maintain well-being in medicine’s challenging milieu. The process of mindfulness—actively drawing distinctions and noticing new things, “seeing the familiar in the novel and the novel in the familiar”—can ensure that we have active minds, that we are involved, and that we are capturing the joy of living in the stimulating present.¹⁸

Focus on issues you can control

Many of the factors that negatively influence professional satisfaction and well-being, such as loss of autonomy, demand for increased patient care volume, and increasing scrutiny on the quality of care, are beyond a psychiatrist’s control. Medical administrators can help reduce some of these issues by increasing physician autonomy, offering physicians the opportunity to work part-time, offering medical staff workshops to enhance positive communication, or addressing leader­ship problems. However, psychiatrists may benefit most by identifying modifiable issues under their own control, such as prioritizing a work–life balance, applying the fundamentals of a health prevention strategy to their own lives (Box^20,21), approaching medicine as a calling, embracing an empathetic approach to patient care, and bringing mindfulness to medical practice.

An abundance of recent neuroscience advances is directly related to psychiatric disorders, because the primary mission of the brain is to generate a mind, and every new discovery provides another piece of the psychiatric disorders puzzle. The time also is ripe to incorporate clinical neuroscience concepts and language in our clinical practice and terminology. The neuroscientification of clinical psychiatry must start with clinical neuro­science literacy.

Although the traditional training of psychiatrists has evolved, it continues to perpetuate the old-fashioned model of care exemplified by the mental status examination, which documents the patient’s appearance, speech, mood, affect, thoughts, perceptions, behavior, cognition, insight, and judgement. Evaluations and progress notes have been constrained by this decades-old formula of observing, interviewing, and documenting signs and symptoms, and arriving at a working diagnosis, followed by a treatment plan comprised of a cluster of drug names, psychotherapeutic modalities, and social or rehabilitation interventions. This widely accepted procedure is important because it focuses on the mind. But where are the details about the brain, whose structural and functional aberrations generate the anomalies of the mind and are the scientific foundations of psychiatric care?

All psychiatrists are fully aware that brain pathology is the source of every psychiatric disorder they evaluate, diagnose, and treat. But it is time to formulate every patient’s care using neuroscience data and include neural mechanisms of the psychiatric disorder in the chart. Our clinical language must be integrated with the rapidly growing neuroscience of abnormalities in brain–behavior links.

Psychiatry is lagging behind neuro­logy, its sister brain specialty, where neural pathways and processes are front and center in describing symptoms. According to Eisenberg,¹ psychiatry training in the 1980s was, for the most part, “brainless.” But it should not remain so, because neuroscience advances have skyrocketed since he made that provocative statement 3 decades ago. Yet, the psychiatric residency training curriculum in many programs is lagging behind the rapid evolution of psychiatry as a clinical neuroscience.²

To its credit, the Accreditation Council for Graduate Medical Education, which oversees and accredits residency training programs in all specialties, including psychiatry, recently announced that psychiatric residency training must emphasize neuroscience competence side-by-side with clinical competence. Psychiatric residents must increasingly incorporate neurobiology in their formulation of clinical care and determine how the selected pharmacologic therapy addresses the dysregulated neural circuitry underlying the clinical manifestation. A good example of this method is a recently published case of posttraumatic stress disorder (PTSD),³ which discussed the clinical components and treatment of this brain disorder through the prism of clinical neuroscience research data. PTSD “trauma” is not only psychological, but also neurobiological, and both must be incorporated in formulating a clinical case.

Another important step has emerged to focus on infusing neuroscience facts and concepts within the clinical training of psychiatric residents. The National Neuroscience Curriculum Initiative (www.nncionline.org) is a timely and welcome initiative that will aggressively promulgate a clinical neuro­scientification of psychiatric training, triggering a roadmap for modern, cutting-edge psychiatric practice.⁴ This will help consolidate psychiatry’s rightful place as a clinical neuroscience, without relinquishing its biopsycho­social roots.

As research continues to elucidate the neural mechanisms of key psychiatric symptoms, such as anxiety, depression, mania, impulsiveness, compulsions, delusions, or hallucinations, the trans­formation of psychiatry into an authentic clinical neuroscience is inevitable. But contemporary psychiatric practitioners must retool and start their journey toward neuroscience literacy by attending relevant continuing medical education presentations and regularly reading journals that focus on clinical psychiatric neuro­science, such as Molecular Psychiatry, JAMA Psychiatry, Biological Psychiatry, Neuropsychopharmacology, and Progress in Neuro-psychopharmacology and Biological Psychiatry. Current Psychiatry will do its part by establishing a section on psychiatric neuroscience for our readers. Dr. Stephen Stahl’s recent guest editorial in Current Psychiatry⁵ about Neuroscience-based Nomenclature is another important step toward the neuroscientification of psychiatric medications’ names, using the neural mechanism of action nomenclature instead of a single clinical indication (eg, antidepressant or antipsychotic) when there may be several approved uses for the medication.

It is my sincere hope that my fellow clinical psychiatrists will steadily grow their clinical neuroscience literacy and apply it to daily patient care. By formulating psychiatric signs and symptoms in evidence-based, neurobiological frameworks provided by clinical neuro­science advances, the myths, shibboleths, and misperceptions of what causes mental illness will dissipate and eventually vanish. And so will the stigma that shrouds our patients who suffer from brain disorders that manifest as disruptions of 1 or more complex functions of the human mind.

An abundance of recent neuroscience advances is directly related to psychiatric disorders, because the primary mission of the brain is to generate a mind, and every new discovery provides another piece of the psychiatric disorders puzzle. The time also is ripe to incorporate clinical neuroscience concepts and language in our clinical practice and terminology. The neuroscientification of clinical psychiatry must start with clinical neuro­science literacy.

Although the traditional training of psychiatrists has evolved, it continues to perpetuate the old-fashioned model of care exemplified by the mental status examination, which documents the patient’s appearance, speech, mood, affect, thoughts, perceptions, behavior, cognition, insight, and judgement. Evaluations and progress notes have been constrained by this decades-old formula of observing, interviewing, and documenting signs and symptoms, and arriving at a working diagnosis, followed by a treatment plan comprised of a cluster of drug names, psychotherapeutic modalities, and social or rehabilitation interventions. This widely accepted procedure is important because it focuses on the mind. But where are the details about the brain, whose structural and functional aberrations generate the anomalies of the mind and are the scientific foundations of psychiatric care?

All psychiatrists are fully aware that brain pathology is the source of every psychiatric disorder they evaluate, diagnose, and treat. But it is time to formulate every patient’s care using neuroscience data and include neural mechanisms of the psychiatric disorder in the chart. Our clinical language must be integrated with the rapidly growing neuroscience of abnormalities in brain–behavior links.

Psychiatry is lagging behind neuro­logy, its sister brain specialty, where neural pathways and processes are front and center in describing symptoms. According to Eisenberg,¹ psychiatry training in the 1980s was, for the most part, “brainless.” But it should not remain so, because neuroscience advances have skyrocketed since he made that provocative statement 3 decades ago. Yet, the psychiatric residency training curriculum in many programs is lagging behind the rapid evolution of psychiatry as a clinical neuroscience.²

To its credit, the Accreditation Council for Graduate Medical Education, which oversees and accredits residency training programs in all specialties, including psychiatry, recently announced that psychiatric residency training must emphasize neuroscience competence side-by-side with clinical competence. Psychiatric residents must increasingly incorporate neurobiology in their formulation of clinical care and determine how the selected pharmacologic therapy addresses the dysregulated neural circuitry underlying the clinical manifestation. A good example of this method is a recently published case of posttraumatic stress disorder (PTSD),³ which discussed the clinical components and treatment of this brain disorder through the prism of clinical neuroscience research data. PTSD “trauma” is not only psychological, but also neurobiological, and both must be incorporated in formulating a clinical case.

Another important step has emerged to focus on infusing neuroscience facts and concepts within the clinical training of psychiatric residents. The National Neuroscience Curriculum Initiative (www.nncionline.org) is a timely and welcome initiative that will aggressively promulgate a clinical neuro­scientification of psychiatric training, triggering a roadmap for modern, cutting-edge psychiatric practice.⁴ This will help consolidate psychiatry’s rightful place as a clinical neuroscience, without relinquishing its biopsycho­social roots.

As research continues to elucidate the neural mechanisms of key psychiatric symptoms, such as anxiety, depression, mania, impulsiveness, compulsions, delusions, or hallucinations, the trans­formation of psychiatry into an authentic clinical neuroscience is inevitable. But contemporary psychiatric practitioners must retool and start their journey toward neuroscience literacy by attending relevant continuing medical education presentations and regularly reading journals that focus on clinical psychiatric neuro­science, such as Molecular Psychiatry, JAMA Psychiatry, Biological Psychiatry, Neuropsychopharmacology, and Progress in Neuro-psychopharmacology and Biological Psychiatry. Current Psychiatry will do its part by establishing a section on psychiatric neuroscience for our readers. Dr. Stephen Stahl’s recent guest editorial in Current Psychiatry⁵ about Neuroscience-based Nomenclature is another important step toward the neuroscientification of psychiatric medications’ names, using the neural mechanism of action nomenclature instead of a single clinical indication (eg, antidepressant or antipsychotic) when there may be several approved uses for the medication.

It is my sincere hope that my fellow clinical psychiatrists will steadily grow their clinical neuroscience literacy and apply it to daily patient care. By formulating psychiatric signs and symptoms in evidence-based, neurobiological frameworks provided by clinical neuro­science advances, the myths, shibboleths, and misperceptions of what causes mental illness will dissipate and eventually vanish. And so will the stigma that shrouds our patients who suffer from brain disorders that manifest as disruptions of 1 or more complex functions of the human mind.

An abundance of recent neuroscience advances is directly related to psychiatric disorders, because the primary mission of the brain is to generate a mind, and every new discovery provides another piece of the psychiatric disorders puzzle. The time also is ripe to incorporate clinical neuroscience concepts and language in our clinical practice and terminology. The neuroscientification of clinical psychiatry must start with clinical neuro­science literacy.

Although the traditional training of psychiatrists has evolved, it continues to perpetuate the old-fashioned model of care exemplified by the mental status examination, which documents the patient’s appearance, speech, mood, affect, thoughts, perceptions, behavior, cognition, insight, and judgement. Evaluations and progress notes have been constrained by this decades-old formula of observing, interviewing, and documenting signs and symptoms, and arriving at a working diagnosis, followed by a treatment plan comprised of a cluster of drug names, psychotherapeutic modalities, and social or rehabilitation interventions. This widely accepted procedure is important because it focuses on the mind. But where are the details about the brain, whose structural and functional aberrations generate the anomalies of the mind and are the scientific foundations of psychiatric care?

All psychiatrists are fully aware that brain pathology is the source of every psychiatric disorder they evaluate, diagnose, and treat. But it is time to formulate every patient’s care using neuroscience data and include neural mechanisms of the psychiatric disorder in the chart. Our clinical language must be integrated with the rapidly growing neuroscience of abnormalities in brain–behavior links.

Psychiatry is lagging behind neuro­logy, its sister brain specialty, where neural pathways and processes are front and center in describing symptoms. According to Eisenberg,¹ psychiatry training in the 1980s was, for the most part, “brainless.” But it should not remain so, because neuroscience advances have skyrocketed since he made that provocative statement 3 decades ago. Yet, the psychiatric residency training curriculum in many programs is lagging behind the rapid evolution of psychiatry as a clinical neuroscience.²

To its credit, the Accreditation Council for Graduate Medical Education, which oversees and accredits residency training programs in all specialties, including psychiatry, recently announced that psychiatric residency training must emphasize neuroscience competence side-by-side with clinical competence. Psychiatric residents must increasingly incorporate neurobiology in their formulation of clinical care and determine how the selected pharmacologic therapy addresses the dysregulated neural circuitry underlying the clinical manifestation. A good example of this method is a recently published case of posttraumatic stress disorder (PTSD),³ which discussed the clinical components and treatment of this brain disorder through the prism of clinical neuroscience research data. PTSD “trauma” is not only psychological, but also neurobiological, and both must be incorporated in formulating a clinical case.

Another important step has emerged to focus on infusing neuroscience facts and concepts within the clinical training of psychiatric residents. The National Neuroscience Curriculum Initiative (www.nncionline.org) is a timely and welcome initiative that will aggressively promulgate a clinical neuro­scientification of psychiatric training, triggering a roadmap for modern, cutting-edge psychiatric practice.⁴ This will help consolidate psychiatry’s rightful place as a clinical neuroscience, without relinquishing its biopsycho­social roots.

As research continues to elucidate the neural mechanisms of key psychiatric symptoms, such as anxiety, depression, mania, impulsiveness, compulsions, delusions, or hallucinations, the trans­formation of psychiatry into an authentic clinical neuroscience is inevitable. But contemporary psychiatric practitioners must retool and start their journey toward neuroscience literacy by attending relevant continuing medical education presentations and regularly reading journals that focus on clinical psychiatric neuro­science, such as Molecular Psychiatry, JAMA Psychiatry, Biological Psychiatry, Neuropsychopharmacology, and Progress in Neuro-psychopharmacology and Biological Psychiatry. Current Psychiatry will do its part by establishing a section on psychiatric neuroscience for our readers. Dr. Stephen Stahl’s recent guest editorial in Current Psychiatry⁵ about Neuroscience-based Nomenclature is another important step toward the neuroscientification of psychiatric medications’ names, using the neural mechanism of action nomenclature instead of a single clinical indication (eg, antidepressant or antipsychotic) when there may be several approved uses for the medication.

It is my sincere hope that my fellow clinical psychiatrists will steadily grow their clinical neuroscience literacy and apply it to daily patient care. By formulating psychiatric signs and symptoms in evidence-based, neurobiological frameworks provided by clinical neuro­science advances, the myths, shibboleths, and misperceptions of what causes mental illness will dissipate and eventually vanish. And so will the stigma that shrouds our patients who suffer from brain disorders that manifest as disruptions of 1 or more complex functions of the human mind.

Dear Dr. Mossman,
I am retired, but an attorney friend of mine has asked me to help out by performing forensic evaluations. I’m tempted to try it because the work sounds meaningful and interesting. I won’t have a doctor–patient relationship with the attorney’s clients, and I expect the work will take <10 hours a week. Do I need malpractice coverage? Should I consider any other medicolegal issues before I start?

Submitted by “Dr. B”

One of the great things about being a psychiatrist is the variety of available practice options. Like Dr. B, many psychiatrists contemplate using their clinical know-how to perform forensic evaluations. For some psychiatrists, part-time work as an expert witness may provide an appealing change of pace from their other clinical duties¹ and a way to supplement their income.²

But as would be true for other kinds of medical practice, Dr. B is wise to consider the possible risks before jumping into forensic work. To help Dr. B decide about getting insurance coverage, we will:

• explain briefly the subspecialty of forensic psychiatry
• review the theory of malpractice and negligence torts
• discuss whether forensic evaluations can create doctor–patient relationships
• explore the availability and limitations of immunity for forensic work
• describe other types of liability with forensic work
• summarize steps to avoid liability.

Introduction to forensic psychiatry

Some psychiatrists—and many people who are not psychiatrists—have a vague or incorrect understanding of forensic psychiatry. Put succinctly, “Forensic Psychiatry is a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts….”³ To practice forensic psychiatry well, a psychiatrist must have some understanding of the law and how to apply and translate clinical concepts to fit legal criteria.⁴ Psychiatrists who offer to serve as expert witnesses should be familiar with how the courtroom functions, the nuances of how expert testimony is used, and possible sources of bias.^4,5

Forensic work can create role conflicts. For most types of forensic assessments, psychiatrists should not provide forensic opinions or testimony about their own patients.³ Even psychiatrists who only work as expert witnesses must balance duties of assisting the trier of fact, fulfilling the consultation role to the retaining party, upholding the standards and ethics of the profession, and striving to provide truthful, objective testimony.²

Special training usually is required

The most important qualification for being a good psychiatric expert witness is being a good psychiatrist, and courts do not require psychiatrists to have specialty training in forensic psychiatry to perform forensic psychiatric evaluations. Yet, the field of forensic psychiatry has developed over the past 50 years to the point that psychiatrists need special training to properly perform many, if not most, types of forensic evaluations.⁶ Much of forensic psychiatry involves writing specialized reports for lawyers and the court,⁷ and experts are supposed to meet professional standards, regardless of their training.^8-10 Psychiatrists who perform forensic work are obligated to claim expertise only in areas where their knowledge, skills, training, and experience justify such claims. These considerations explain why, since 1999, the American Board of Psychiatry and Neurology has limited eligibility for board certification in forensic psychiatry to psychiatrists who have completed accredited forensic fellowships.¹¹

Malpractice: A short review

To address Dr. B’s question about malpractice coverage, we first review what malpractice is.

“Tort” is a legal term for injury, and tort claims arise when one party harms another and the harmed party seeks money as compensation.⁹ In a tort claim alleging negligence, the plaintiff (ie, the person bringing the suit) asserts that the defendant had a legally recognized duty, that the defendant breached that duty, and that breach of duty harmed the plaintiff.⁸

Physicians have a legal duty to “possess the requisite knowledge and skill such as is possessed by the average member of the medical profession; … exercise ordinary and reasonable care in the application of such knowledge and skill; and … use best judgment in such application.”¹⁰ A medical malpractice lawsuit asserts that a doctor breached this duty and caused injury in the course of the medical practice.

Malpractice in forensic cases

Practicing medicine typically occurs within the context of treatment relationships. One might think, as Dr. B did, that because forensic evaluations do not involve treating patients, they do not create the kind of doctor–patient relationship that could lead to malpractice liability. This is incorrect, however, for several reasons.

Certain well-intended actions during a forensic evaluation, such as explaining the implications of a diagnosis, giving specific advice about a medication, or making a recommendation about where or how to obtain treatment, may create a doctor–patient relationship.^12,13 Many states’ laws on what constitutes the practice of medicine include performing examinations, diagnosing, or referring to oneself as “Dr.” or as a medical practitioner.^14-17 State courts have interpreted these laws to further define what constitutes medical practice and the creation of a doctor–patient relationship during a forensic examination.^18,19 Some legal scholars²⁰ and the American Medical Association (AMA)⁹ regard provision of expert testimony as practicing medicine because such testimony requires the application of medical science and rendering of diagnoses.

Immunity and shifts away from it

For many years, courts granted civil immunity to expert witnesses for several policy reasons.^8,9,13,20-22 Courts recognized that losing parties might want to blame whomever they could, and immunity could provide legal protection for expert witnesses. Without such protection, witnesses might feel more pressured to give testimony favorable to their side at the loss of objectivity,^23,24 or experts might be discouraged from testifying at all. This would be true especially for academic psychiatrists who testify infrequently or for retired doctors, such as Dr. B, who might not want to carry insurance for just one case.²¹ According to this argument, rather than using the threat of litigation to keep out improper testimony, courts should rely on both admissibility standards^25,26 and the adversarial nature of proceedings.²¹

Those who oppose granting immunity to experts argue that admissibility rules and cross-examination do too little to prevent bad testimony; the threat of liability, however, motivates experts to be more cautious and scientifically rigorous in their approach.²¹ Opponents also have argued that the threat of liability might reduce improper testimony, which they believe was partly responsible for rising malpractice premiums.²⁰

Courts vary in how they consider granting immunity and to what extent. For example:

• Some courts will not grant immunity to so-called “friendly experts,” while others have limited immunity for adversarial experts.^20-22
• Some courts have applied immunity to general fact witnesses but not to professional experts.^21,24,27
• When immunity is considered, it is usually regarding actual testimony. Yet, some courts have included pretrial services.^21,28-30
• Some courts have considered the testimonial issue at hand when deciding whether to extend immunity. For example, immunity may not apply if the issue is loss of profits^21,31 or if an experiment is conducted to demonstrate the extent of a physical injury.^21,32

If you plan to serve as an expert witness, find out what, if any, immunity is available in the jurisdiction where you expect to testify. If you do not have immunity, you may be subject to various malpractice claims, including alleged physical or emotional harm resulting from the evaluation¹ (perhaps caused by misuse of empathic statements³³), an accusation of negligent misdiagnosis of an evaluee,⁸ or failing to act upon a duty to warn or protect that arises during an assessment.³⁴

Other liability

Dr. B also asked about medicolegal issues other than malpractice. Although negligence is the claim that forensic psychiatrists most commonly encounter,¹⁰ other types of claims arise in practice-related legal actions. Potential causes of action include failure to obtain or attempt to obtain informed consent, breach of confidentiality, or not responding to a psychiatric emergency during evaluation. The plaintiff usually must show that the expert’s conduct was the cause-in-fact of injury.⁸

Besides civil lawsuits, forensic work may generate complaints to state medical boards.¹⁰ Occasionally, state medical boards have revoked psychiatrists’ licenses for improper testimony.²⁰ Aggrieved parties may allege violations of the Health Insurance Portability and Accountability Act of 1996, such as mishandling protected health information. Psychiatrists also may face sanction by professional societies—for example, censure by the American Psychiatric Association^9,10 or the AMA¹³ for ethics violations—if their improper testimony is considered unprofessional conduct. The theory behind this is that judges and jurors cannot be technical experts in every field, so the field must have a mechanism to police itself.^20,35,36 Finally, forensic experts can face criminal charges for perjury if they lie under oath.⁸

How to protect yourself

Even when legal claims against psychiatrists turn out to be baseless, legal costs of defending oneself can mount quickly. Knowing this, Dr. B may conclude that obtaining malpractice insurance would be wise. But a malpractice policy alone may not meet all Dr. B’s needs, because some policies do not cover ordinary negligence or other potential causes of legal action against a psychiatrist.¹³ Some companies offer these extra types of coverage for work as an expert witness at no additional cost, and some offer access to risk management services with specialized knowledge about forensic psychiatric practice.

Dear Dr. Mossman,
I am retired, but an attorney friend of mine has asked me to help out by performing forensic evaluations. I’m tempted to try it because the work sounds meaningful and interesting. I won’t have a doctor–patient relationship with the attorney’s clients, and I expect the work will take <10 hours a week. Do I need malpractice coverage? Should I consider any other medicolegal issues before I start?

Submitted by “Dr. B”

One of the great things about being a psychiatrist is the variety of available practice options. Like Dr. B, many psychiatrists contemplate using their clinical know-how to perform forensic evaluations. For some psychiatrists, part-time work as an expert witness may provide an appealing change of pace from their other clinical duties¹ and a way to supplement their income.²

But as would be true for other kinds of medical practice, Dr. B is wise to consider the possible risks before jumping into forensic work. To help Dr. B decide about getting insurance coverage, we will:

• explain briefly the subspecialty of forensic psychiatry
• review the theory of malpractice and negligence torts
• discuss whether forensic evaluations can create doctor–patient relationships
• explore the availability and limitations of immunity for forensic work
• describe other types of liability with forensic work
• summarize steps to avoid liability.

Introduction to forensic psychiatry

Some psychiatrists—and many people who are not psychiatrists—have a vague or incorrect understanding of forensic psychiatry. Put succinctly, “Forensic Psychiatry is a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts….”³ To practice forensic psychiatry well, a psychiatrist must have some understanding of the law and how to apply and translate clinical concepts to fit legal criteria.⁴ Psychiatrists who offer to serve as expert witnesses should be familiar with how the courtroom functions, the nuances of how expert testimony is used, and possible sources of bias.^4,5

Forensic work can create role conflicts. For most types of forensic assessments, psychiatrists should not provide forensic opinions or testimony about their own patients.³ Even psychiatrists who only work as expert witnesses must balance duties of assisting the trier of fact, fulfilling the consultation role to the retaining party, upholding the standards and ethics of the profession, and striving to provide truthful, objective testimony.²

Special training usually is required

The most important qualification for being a good psychiatric expert witness is being a good psychiatrist, and courts do not require psychiatrists to have specialty training in forensic psychiatry to perform forensic psychiatric evaluations. Yet, the field of forensic psychiatry has developed over the past 50 years to the point that psychiatrists need special training to properly perform many, if not most, types of forensic evaluations.⁶ Much of forensic psychiatry involves writing specialized reports for lawyers and the court,⁷ and experts are supposed to meet professional standards, regardless of their training.^8-10 Psychiatrists who perform forensic work are obligated to claim expertise only in areas where their knowledge, skills, training, and experience justify such claims. These considerations explain why, since 1999, the American Board of Psychiatry and Neurology has limited eligibility for board certification in forensic psychiatry to psychiatrists who have completed accredited forensic fellowships.¹¹

Malpractice: A short review

To address Dr. B’s question about malpractice coverage, we first review what malpractice is.

“Tort” is a legal term for injury, and tort claims arise when one party harms another and the harmed party seeks money as compensation.⁹ In a tort claim alleging negligence, the plaintiff (ie, the person bringing the suit) asserts that the defendant had a legally recognized duty, that the defendant breached that duty, and that breach of duty harmed the plaintiff.⁸

Physicians have a legal duty to “possess the requisite knowledge and skill such as is possessed by the average member of the medical profession; … exercise ordinary and reasonable care in the application of such knowledge and skill; and … use best judgment in such application.”¹⁰ A medical malpractice lawsuit asserts that a doctor breached this duty and caused injury in the course of the medical practice.

Malpractice in forensic cases

Practicing medicine typically occurs within the context of treatment relationships. One might think, as Dr. B did, that because forensic evaluations do not involve treating patients, they do not create the kind of doctor–patient relationship that could lead to malpractice liability. This is incorrect, however, for several reasons.

Certain well-intended actions during a forensic evaluation, such as explaining the implications of a diagnosis, giving specific advice about a medication, or making a recommendation about where or how to obtain treatment, may create a doctor–patient relationship.^12,13 Many states’ laws on what constitutes the practice of medicine include performing examinations, diagnosing, or referring to oneself as “Dr.” or as a medical practitioner.^14-17 State courts have interpreted these laws to further define what constitutes medical practice and the creation of a doctor–patient relationship during a forensic examination.^18,19 Some legal scholars²⁰ and the American Medical Association (AMA)⁹ regard provision of expert testimony as practicing medicine because such testimony requires the application of medical science and rendering of diagnoses.

Immunity and shifts away from it

For many years, courts granted civil immunity to expert witnesses for several policy reasons.^8,9,13,20-22 Courts recognized that losing parties might want to blame whomever they could, and immunity could provide legal protection for expert witnesses. Without such protection, witnesses might feel more pressured to give testimony favorable to their side at the loss of objectivity,^23,24 or experts might be discouraged from testifying at all. This would be true especially for academic psychiatrists who testify infrequently or for retired doctors, such as Dr. B, who might not want to carry insurance for just one case.²¹ According to this argument, rather than using the threat of litigation to keep out improper testimony, courts should rely on both admissibility standards^25,26 and the adversarial nature of proceedings.²¹

Those who oppose granting immunity to experts argue that admissibility rules and cross-examination do too little to prevent bad testimony; the threat of liability, however, motivates experts to be more cautious and scientifically rigorous in their approach.²¹ Opponents also have argued that the threat of liability might reduce improper testimony, which they believe was partly responsible for rising malpractice premiums.²⁰

Courts vary in how they consider granting immunity and to what extent. For example:

• Some courts will not grant immunity to so-called “friendly experts,” while others have limited immunity for adversarial experts.^20-22
• Some courts have applied immunity to general fact witnesses but not to professional experts.^21,24,27
• When immunity is considered, it is usually regarding actual testimony. Yet, some courts have included pretrial services.^21,28-30
• Some courts have considered the testimonial issue at hand when deciding whether to extend immunity. For example, immunity may not apply if the issue is loss of profits^21,31 or if an experiment is conducted to demonstrate the extent of a physical injury.^21,32

If you plan to serve as an expert witness, find out what, if any, immunity is available in the jurisdiction where you expect to testify. If you do not have immunity, you may be subject to various malpractice claims, including alleged physical or emotional harm resulting from the evaluation¹ (perhaps caused by misuse of empathic statements³³), an accusation of negligent misdiagnosis of an evaluee,⁸ or failing to act upon a duty to warn or protect that arises during an assessment.³⁴

Other liability

Dr. B also asked about medicolegal issues other than malpractice. Although negligence is the claim that forensic psychiatrists most commonly encounter,¹⁰ other types of claims arise in practice-related legal actions. Potential causes of action include failure to obtain or attempt to obtain informed consent, breach of confidentiality, or not responding to a psychiatric emergency during evaluation. The plaintiff usually must show that the expert’s conduct was the cause-in-fact of injury.⁸

Besides civil lawsuits, forensic work may generate complaints to state medical boards.¹⁰ Occasionally, state medical boards have revoked psychiatrists’ licenses for improper testimony.²⁰ Aggrieved parties may allege violations of the Health Insurance Portability and Accountability Act of 1996, such as mishandling protected health information. Psychiatrists also may face sanction by professional societies—for example, censure by the American Psychiatric Association^9,10 or the AMA¹³ for ethics violations—if their improper testimony is considered unprofessional conduct. The theory behind this is that judges and jurors cannot be technical experts in every field, so the field must have a mechanism to police itself.^20,35,36 Finally, forensic experts can face criminal charges for perjury if they lie under oath.⁸

How to protect yourself

Even when legal claims against psychiatrists turn out to be baseless, legal costs of defending oneself can mount quickly. Knowing this, Dr. B may conclude that obtaining malpractice insurance would be wise. But a malpractice policy alone may not meet all Dr. B’s needs, because some policies do not cover ordinary negligence or other potential causes of legal action against a psychiatrist.¹³ Some companies offer these extra types of coverage for work as an expert witness at no additional cost, and some offer access to risk management services with specialized knowledge about forensic psychiatric practice.

Dear Dr. Mossman,
I am retired, but an attorney friend of mine has asked me to help out by performing forensic evaluations. I’m tempted to try it because the work sounds meaningful and interesting. I won’t have a doctor–patient relationship with the attorney’s clients, and I expect the work will take <10 hours a week. Do I need malpractice coverage? Should I consider any other medicolegal issues before I start?

Submitted by “Dr. B”

One of the great things about being a psychiatrist is the variety of available practice options. Like Dr. B, many psychiatrists contemplate using their clinical know-how to perform forensic evaluations. For some psychiatrists, part-time work as an expert witness may provide an appealing change of pace from their other clinical duties¹ and a way to supplement their income.²

But as would be true for other kinds of medical practice, Dr. B is wise to consider the possible risks before jumping into forensic work. To help Dr. B decide about getting insurance coverage, we will:

• explain briefly the subspecialty of forensic psychiatry
• review the theory of malpractice and negligence torts
• discuss whether forensic evaluations can create doctor–patient relationships
• explore the availability and limitations of immunity for forensic work
• describe other types of liability with forensic work
• summarize steps to avoid liability.

Introduction to forensic psychiatry

Some psychiatrists—and many people who are not psychiatrists—have a vague or incorrect understanding of forensic psychiatry. Put succinctly, “Forensic Psychiatry is a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts….”³ To practice forensic psychiatry well, a psychiatrist must have some understanding of the law and how to apply and translate clinical concepts to fit legal criteria.⁴ Psychiatrists who offer to serve as expert witnesses should be familiar with how the courtroom functions, the nuances of how expert testimony is used, and possible sources of bias.^4,5

Forensic work can create role conflicts. For most types of forensic assessments, psychiatrists should not provide forensic opinions or testimony about their own patients.³ Even psychiatrists who only work as expert witnesses must balance duties of assisting the trier of fact, fulfilling the consultation role to the retaining party, upholding the standards and ethics of the profession, and striving to provide truthful, objective testimony.²

Special training usually is required

The most important qualification for being a good psychiatric expert witness is being a good psychiatrist, and courts do not require psychiatrists to have specialty training in forensic psychiatry to perform forensic psychiatric evaluations. Yet, the field of forensic psychiatry has developed over the past 50 years to the point that psychiatrists need special training to properly perform many, if not most, types of forensic evaluations.⁶ Much of forensic psychiatry involves writing specialized reports for lawyers and the court,⁷ and experts are supposed to meet professional standards, regardless of their training.^8-10 Psychiatrists who perform forensic work are obligated to claim expertise only in areas where their knowledge, skills, training, and experience justify such claims. These considerations explain why, since 1999, the American Board of Psychiatry and Neurology has limited eligibility for board certification in forensic psychiatry to psychiatrists who have completed accredited forensic fellowships.¹¹

Malpractice: A short review

To address Dr. B’s question about malpractice coverage, we first review what malpractice is.

“Tort” is a legal term for injury, and tort claims arise when one party harms another and the harmed party seeks money as compensation.⁹ In a tort claim alleging negligence, the plaintiff (ie, the person bringing the suit) asserts that the defendant had a legally recognized duty, that the defendant breached that duty, and that breach of duty harmed the plaintiff.⁸

Physicians have a legal duty to “possess the requisite knowledge and skill such as is possessed by the average member of the medical profession; … exercise ordinary and reasonable care in the application of such knowledge and skill; and … use best judgment in such application.”¹⁰ A medical malpractice lawsuit asserts that a doctor breached this duty and caused injury in the course of the medical practice.

Malpractice in forensic cases

Practicing medicine typically occurs within the context of treatment relationships. One might think, as Dr. B did, that because forensic evaluations do not involve treating patients, they do not create the kind of doctor–patient relationship that could lead to malpractice liability. This is incorrect, however, for several reasons.

Certain well-intended actions during a forensic evaluation, such as explaining the implications of a diagnosis, giving specific advice about a medication, or making a recommendation about where or how to obtain treatment, may create a doctor–patient relationship.^12,13 Many states’ laws on what constitutes the practice of medicine include performing examinations, diagnosing, or referring to oneself as “Dr.” or as a medical practitioner.^14-17 State courts have interpreted these laws to further define what constitutes medical practice and the creation of a doctor–patient relationship during a forensic examination.^18,19 Some legal scholars²⁰ and the American Medical Association (AMA)⁹ regard provision of expert testimony as practicing medicine because such testimony requires the application of medical science and rendering of diagnoses.

Immunity and shifts away from it

For many years, courts granted civil immunity to expert witnesses for several policy reasons.^8,9,13,20-22 Courts recognized that losing parties might want to blame whomever they could, and immunity could provide legal protection for expert witnesses. Without such protection, witnesses might feel more pressured to give testimony favorable to their side at the loss of objectivity,^23,24 or experts might be discouraged from testifying at all. This would be true especially for academic psychiatrists who testify infrequently or for retired doctors, such as Dr. B, who might not want to carry insurance for just one case.²¹ According to this argument, rather than using the threat of litigation to keep out improper testimony, courts should rely on both admissibility standards^25,26 and the adversarial nature of proceedings.²¹

Those who oppose granting immunity to experts argue that admissibility rules and cross-examination do too little to prevent bad testimony; the threat of liability, however, motivates experts to be more cautious and scientifically rigorous in their approach.²¹ Opponents also have argued that the threat of liability might reduce improper testimony, which they believe was partly responsible for rising malpractice premiums.²⁰

Courts vary in how they consider granting immunity and to what extent. For example:

• Some courts will not grant immunity to so-called “friendly experts,” while others have limited immunity for adversarial experts.^20-22
• Some courts have applied immunity to general fact witnesses but not to professional experts.^21,24,27
• When immunity is considered, it is usually regarding actual testimony. Yet, some courts have included pretrial services.^21,28-30
• Some courts have considered the testimonial issue at hand when deciding whether to extend immunity. For example, immunity may not apply if the issue is loss of profits^21,31 or if an experiment is conducted to demonstrate the extent of a physical injury.^21,32

If you plan to serve as an expert witness, find out what, if any, immunity is available in the jurisdiction where you expect to testify. If you do not have immunity, you may be subject to various malpractice claims, including alleged physical or emotional harm resulting from the evaluation¹ (perhaps caused by misuse of empathic statements³³), an accusation of negligent misdiagnosis of an evaluee,⁸ or failing to act upon a duty to warn or protect that arises during an assessment.³⁴

Other liability

Dr. B also asked about medicolegal issues other than malpractice. Although negligence is the claim that forensic psychiatrists most commonly encounter,¹⁰ other types of claims arise in practice-related legal actions. Potential causes of action include failure to obtain or attempt to obtain informed consent, breach of confidentiality, or not responding to a psychiatric emergency during evaluation. The plaintiff usually must show that the expert’s conduct was the cause-in-fact of injury.⁸

Besides civil lawsuits, forensic work may generate complaints to state medical boards.¹⁰ Occasionally, state medical boards have revoked psychiatrists’ licenses for improper testimony.²⁰ Aggrieved parties may allege violations of the Health Insurance Portability and Accountability Act of 1996, such as mishandling protected health information. Psychiatrists also may face sanction by professional societies—for example, censure by the American Psychiatric Association^9,10 or the AMA¹³ for ethics violations—if their improper testimony is considered unprofessional conduct. The theory behind this is that judges and jurors cannot be technical experts in every field, so the field must have a mechanism to police itself.^20,35,36 Finally, forensic experts can face criminal charges for perjury if they lie under oath.⁸

How to protect yourself

Even when legal claims against psychiatrists turn out to be baseless, legal costs of defending oneself can mount quickly. Knowing this, Dr. B may conclude that obtaining malpractice insurance would be wise. But a malpractice policy alone may not meet all Dr. B’s needs, because some policies do not cover ordinary negligence or other potential causes of legal action against a psychiatrist.¹³ Some companies offer these extra types of coverage for work as an expert witness at no additional cost, and some offer access to risk management services with specialized knowledge about forensic psychiatric practice.

CASE Sleepless, hallucinating

Mr. F, age 30, is brought to the emergency department (ED) by his brother, with whom he has been living for the last 2 days; his brother says that Mr. F’s wife is afraid of her husband and concerned about her children’s safety. Mr. F has been talking to himself, saying “odd things,” and has an unpredictable temper. He claims that his long-deceased father is alive and telling him “to move to a land that he brought [sic] for him.” In order to follow his father’s instructions, Mr. F says he wants to “see the ambassador so he can get his passport ready.” He also believes his wife and children are intruders in his home. Although he had never smoked before, Mr. F has started smoking ≥2 packs of cigarettes per day, sometimes smoking a pack in 30 minutes. He has not eaten or slept for the last 2 days and lies awake in bed all night staring at the ceiling and smiling to himself.

On examination, Mr. F is short with a slight build and has large, dark eyes, disheveled, short, brown hair, and a scraggly beard. English is not his first language, and he speaks with a thick Eastern European accent. His speech is latent, monotonous, tangential, and illogical. He is alert, oriented only to his person, and says he is 21 or 27 years old and at the hospital for “smoking medication and that’s it.” Despite immigrating to the United States 8 years ago, Mr. F claims he has spent his whole life “here,” although he is unsure of exactly where that is. Cognition and memory are impaired. Regarding his wife and 5 children, he says, “I am a virgin. How then can I have children? That woman is abusing me by forcefully entering my house with 5 kids.” He is fidgety, appears anxious, and does not make eye contact with the examiner during the interview. He is suspicious and irritable. Initial medical workup in the ED is negative.

[polldaddy:9813268]

EVALUATION Labs and observation

Because Mr. F had delusions and hallucinations for the past 2 days and the initial medical workup was negative, brief psychotic disorder is suspected.¹ He is admitted to a secure psychiatric floor for further evaluation. He has no documented medical history. A thorough medical workup for a cause of his hallucinations and delusions, including EEG and brain MRI, is negative. Additional collateral interviews with Mr. F’s wife and brother at a family meeting indicate Mr. F had a slow onset of symptoms that began 4 to 5 years ago. Initially, he became isolated, withdrawn, inactive, and had poor sleep. Recently, he also had become suspicious, irritable, delusional, and hallucinatory. Mr. F used to work full-time in construction, then began working intermittently in a warehouse as a day laborer, but has not worked for the last few months. He used to be an involved father and reliable partner, helping with household chores and caring for the children. However, for the last few months, he had become increasingly apathetic and isolated.

During the comprehensive workup for psychosis, Mr. F’s symptoms continue. He is disoriented; although it is 2015, he states it is “2007… I carry a cell phone so I don’t need to know.” On July 31, he is told the date, and for several days after that, he states that it is July 31. When asked his birth date, he looks at his hospital wrist ID. His affect is flat, but he states he feels “fine” and smiles at inappropriate times. He answers open-ended questions briefly, with irrelevant or illogical answers after long pauses, or not at all. His eye contact is poor; he seems preoccupied with internal stimuli, and it is difficult to keep his attention.
 

Mr. F says he is a “natural-born Bosnian gypsy translator,” and that he needs to finish “building the warehouse” with his father and grandfather (both are deceased). The nurses note that he is withdrawn, inactive, and suspicious; he spends most of the day lying in bed awake, and in the evening he paces in the hallway. Mr. F does not interact with other patients, is guarded when questioned, and does not eat much. He has minimal insight into his condition and says that he is at the hospital for “fevers and a cold,” “ESL treatment,” or because his “right side is thicker” than his left. It is unclear what Mr. F means by “ESL.” It may refer to English as a Second Language, given his apparent perseveration regarding his immigration status and language ability, but this is speculation.

[polldaddy:9813271]

TREATMENT Residual symptoms

With the additional collateral history and a negative medical workup, Mr. F meets DSM-5 criteria for acute, first-episode schizophrenia¹ and is started on risperidone, 2 mg/d, titrated up to 2 mg twice daily, and trazodone, 50 mg, as needed, as a sleep aid. He shows significant improvement in his symptoms early in his treatment course. During visiting hours and at family meetings, he recognizes his wife, and during interviews he denies any continuing hallucinations. He initially says that he never failed to recognize his wife and kids, but later explains that he “woke up different…from a dream, and she was a different woman.” When asked specifically about hearing his father’s voice, he is uncertain, saying “No,” “I don’t know,” “I didn’t hear,” or “Not anymore.”

Despite his improvement, Mr. F continues to be disoriented and suspicious, and has minimal insight into his illness. He also continues to exhibit significant negative symptoms and cognitive impairment. Mr. F is withdrawn and has a flat affect, poverty of speech, delayed processing, and poor focus and attention.

On hospital Day 6, Mr. F reports feeling depressed. He misses his children and wants to go home. He has lost several pounds because he had a poor appetite and is now underweight. He is apathetic; interactions with staff and patients are minimal, he declines to attend group therapy sessions, and he still spends most of his time lying in bed awake or pacing the hallway. He also expresses a desire to quit smoking.

[polldaddy:9813273]

The authors’ observations

Despite its lack of specific inclusion in the DSM-5 criteria,¹ cognitive impairment is a distinct, core, and nearly universal feature of schizophrenia. As demonstrated by Mr. F’s case, the severity of cognitive impairment in schizophrenia has no association with the positive symptoms of schizophrenia; it is a patient’s neuro­cognitive abilities—not the severity of his (her) psychotic symptoms—that most strongly predict functional outcomes.²

Neurocognitive impairment is a strong contributor to and predictor of disability in schizophrenia.^3,4 Treatment of the cognitive symptoms of schizophrenia with antipsychotics has been largely ineffective.² Effective drug therapy regimens are still being developed, and although there are some promising novel targets, no drug is FDA-approved to treat the cognitive symptoms of schizophrenia.^2,4 However, it is known that additional treatment modalities, including social skills training and/or vocational rehabilitation, as well as treatment of comorbid conditions, may lead to improved cognitive status and, as a result, improved functional outcomes in schizophrenia.^2-4

It is well documented that persons with schizophrenia in households with high expressed emotion (EE) have higher rates of relapse, independent of demographics and pharmacotherapy.⁵ EE is a measure of the family environment that evaluates how the relatives of a psychiatric patient spontaneously talk about the patient. Relatives are considered to have high EE if they show hostility or marked emotional overinvolvement, or if they make a certain number of critical comments. The tool used to measure EE is the Camberwell Family Interview Schedule.^6,7 Rates of first-year relapse in high EE homes when family treatment is employed drop significantly, especially when combined with social skills training.⁸ The patient’s family members are educated about EE and its potential negative effects on the patient.

Cognitive remediation therapy (CRT) uses therapist-led, computer-based techniques to preserve intact neuroplasticity and has been shown to improve cognition and functional status, especially when paired with vocational rehabilitation or social skills training.^2,3 Many trials confirm that CRT produces meaningful, durable improvements in cognition and functioning.³ One systematic review that focused on trials in early schizophrenia found that CRT had a significant effect on functioning and symptoms, and that these effects were larger when CRT was combined with adjunctive psychiatric rehabilitation and small group interventions.³

OUTCOME Gradual improvement

Mr. F is started on nicotine gum, 2 mg/d, for smoking cessation and fluoxetine, 20 mg/d, for depression, and a dietary consult is made for his poor appetite and weight loss. His psychotic symptoms continue to improve, and by hospital Day 10, his depressive symptoms begin to improve as well: his affect brightens, he has increased appetite, and he wants to shave. He also exhibits mildly increased insight into his illness.

The authors’ observations

A major goal of the National Institute of Mental Health’s Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative was to develop a consensus cognitive battery for clinical trials of cognition-enhancing treatments for schizophrenia. The MATRICS Consensus Cognitive Battery (MCCB) is a comprehensive cognitive assessment designed for use in patients with schizophrenia (Table 3⁹). Although the MCCB was developed to be the standard tool for assessing cognitive change in clinical trials of cognition-enhancing drugs for schizophrenia, it also may aid evaluation of cognitive remediation strategies.⁹

In Mr. F’s case, such testing was not performed, in part because of his improvement. The MoCA was chosen because it is a universally accepted brief cognitive assessment tool used for screening. More robust testing can be administered by the neuropsychiatry team if indicated and if resources are available.

CASE Sleepless, hallucinating

Mr. F, age 30, is brought to the emergency department (ED) by his brother, with whom he has been living for the last 2 days; his brother says that Mr. F’s wife is afraid of her husband and concerned about her children’s safety. Mr. F has been talking to himself, saying “odd things,” and has an unpredictable temper. He claims that his long-deceased father is alive and telling him “to move to a land that he brought [sic] for him.” In order to follow his father’s instructions, Mr. F says he wants to “see the ambassador so he can get his passport ready.” He also believes his wife and children are intruders in his home. Although he had never smoked before, Mr. F has started smoking ≥2 packs of cigarettes per day, sometimes smoking a pack in 30 minutes. He has not eaten or slept for the last 2 days and lies awake in bed all night staring at the ceiling and smiling to himself.

On examination, Mr. F is short with a slight build and has large, dark eyes, disheveled, short, brown hair, and a scraggly beard. English is not his first language, and he speaks with a thick Eastern European accent. His speech is latent, monotonous, tangential, and illogical. He is alert, oriented only to his person, and says he is 21 or 27 years old and at the hospital for “smoking medication and that’s it.” Despite immigrating to the United States 8 years ago, Mr. F claims he has spent his whole life “here,” although he is unsure of exactly where that is. Cognition and memory are impaired. Regarding his wife and 5 children, he says, “I am a virgin. How then can I have children? That woman is abusing me by forcefully entering my house with 5 kids.” He is fidgety, appears anxious, and does not make eye contact with the examiner during the interview. He is suspicious and irritable. Initial medical workup in the ED is negative.

[polldaddy:9813268]

EVALUATION Labs and observation

Because Mr. F had delusions and hallucinations for the past 2 days and the initial medical workup was negative, brief psychotic disorder is suspected.¹ He is admitted to a secure psychiatric floor for further evaluation. He has no documented medical history. A thorough medical workup for a cause of his hallucinations and delusions, including EEG and brain MRI, is negative. Additional collateral interviews with Mr. F’s wife and brother at a family meeting indicate Mr. F had a slow onset of symptoms that began 4 to 5 years ago. Initially, he became isolated, withdrawn, inactive, and had poor sleep. Recently, he also had become suspicious, irritable, delusional, and hallucinatory. Mr. F used to work full-time in construction, then began working intermittently in a warehouse as a day laborer, but has not worked for the last few months. He used to be an involved father and reliable partner, helping with household chores and caring for the children. However, for the last few months, he had become increasingly apathetic and isolated.

During the comprehensive workup for psychosis, Mr. F’s symptoms continue. He is disoriented; although it is 2015, he states it is “2007… I carry a cell phone so I don’t need to know.” On July 31, he is told the date, and for several days after that, he states that it is July 31. When asked his birth date, he looks at his hospital wrist ID. His affect is flat, but he states he feels “fine” and smiles at inappropriate times. He answers open-ended questions briefly, with irrelevant or illogical answers after long pauses, or not at all. His eye contact is poor; he seems preoccupied with internal stimuli, and it is difficult to keep his attention.
 

Mr. F says he is a “natural-born Bosnian gypsy translator,” and that he needs to finish “building the warehouse” with his father and grandfather (both are deceased). The nurses note that he is withdrawn, inactive, and suspicious; he spends most of the day lying in bed awake, and in the evening he paces in the hallway. Mr. F does not interact with other patients, is guarded when questioned, and does not eat much. He has minimal insight into his condition and says that he is at the hospital for “fevers and a cold,” “ESL treatment,” or because his “right side is thicker” than his left. It is unclear what Mr. F means by “ESL.” It may refer to English as a Second Language, given his apparent perseveration regarding his immigration status and language ability, but this is speculation.

[polldaddy:9813271]

TREATMENT Residual symptoms

With the additional collateral history and a negative medical workup, Mr. F meets DSM-5 criteria for acute, first-episode schizophrenia¹ and is started on risperidone, 2 mg/d, titrated up to 2 mg twice daily, and trazodone, 50 mg, as needed, as a sleep aid. He shows significant improvement in his symptoms early in his treatment course. During visiting hours and at family meetings, he recognizes his wife, and during interviews he denies any continuing hallucinations. He initially says that he never failed to recognize his wife and kids, but later explains that he “woke up different…from a dream, and she was a different woman.” When asked specifically about hearing his father’s voice, he is uncertain, saying “No,” “I don’t know,” “I didn’t hear,” or “Not anymore.”

Despite his improvement, Mr. F continues to be disoriented and suspicious, and has minimal insight into his illness. He also continues to exhibit significant negative symptoms and cognitive impairment. Mr. F is withdrawn and has a flat affect, poverty of speech, delayed processing, and poor focus and attention.

On hospital Day 6, Mr. F reports feeling depressed. He misses his children and wants to go home. He has lost several pounds because he had a poor appetite and is now underweight. He is apathetic; interactions with staff and patients are minimal, he declines to attend group therapy sessions, and he still spends most of his time lying in bed awake or pacing the hallway. He also expresses a desire to quit smoking.

[polldaddy:9813273]

The authors’ observations

Despite its lack of specific inclusion in the DSM-5 criteria,¹ cognitive impairment is a distinct, core, and nearly universal feature of schizophrenia. As demonstrated by Mr. F’s case, the severity of cognitive impairment in schizophrenia has no association with the positive symptoms of schizophrenia; it is a patient’s neuro­cognitive abilities—not the severity of his (her) psychotic symptoms—that most strongly predict functional outcomes.²

Neurocognitive impairment is a strong contributor to and predictor of disability in schizophrenia.^3,4 Treatment of the cognitive symptoms of schizophrenia with antipsychotics has been largely ineffective.² Effective drug therapy regimens are still being developed, and although there are some promising novel targets, no drug is FDA-approved to treat the cognitive symptoms of schizophrenia.^2,4 However, it is known that additional treatment modalities, including social skills training and/or vocational rehabilitation, as well as treatment of comorbid conditions, may lead to improved cognitive status and, as a result, improved functional outcomes in schizophrenia.^2-4

It is well documented that persons with schizophrenia in households with high expressed emotion (EE) have higher rates of relapse, independent of demographics and pharmacotherapy.⁵ EE is a measure of the family environment that evaluates how the relatives of a psychiatric patient spontaneously talk about the patient. Relatives are considered to have high EE if they show hostility or marked emotional overinvolvement, or if they make a certain number of critical comments. The tool used to measure EE is the Camberwell Family Interview Schedule.^6,7 Rates of first-year relapse in high EE homes when family treatment is employed drop significantly, especially when combined with social skills training.⁸ The patient’s family members are educated about EE and its potential negative effects on the patient.

Cognitive remediation therapy (CRT) uses therapist-led, computer-based techniques to preserve intact neuroplasticity and has been shown to improve cognition and functional status, especially when paired with vocational rehabilitation or social skills training.^2,3 Many trials confirm that CRT produces meaningful, durable improvements in cognition and functioning.³ One systematic review that focused on trials in early schizophrenia found that CRT had a significant effect on functioning and symptoms, and that these effects were larger when CRT was combined with adjunctive psychiatric rehabilitation and small group interventions.³

OUTCOME Gradual improvement

Mr. F is started on nicotine gum, 2 mg/d, for smoking cessation and fluoxetine, 20 mg/d, for depression, and a dietary consult is made for his poor appetite and weight loss. His psychotic symptoms continue to improve, and by hospital Day 10, his depressive symptoms begin to improve as well: his affect brightens, he has increased appetite, and he wants to shave. He also exhibits mildly increased insight into his illness.

The authors’ observations

A major goal of the National Institute of Mental Health’s Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative was to develop a consensus cognitive battery for clinical trials of cognition-enhancing treatments for schizophrenia. The MATRICS Consensus Cognitive Battery (MCCB) is a comprehensive cognitive assessment designed for use in patients with schizophrenia (Table 3⁹). Although the MCCB was developed to be the standard tool for assessing cognitive change in clinical trials of cognition-enhancing drugs for schizophrenia, it also may aid evaluation of cognitive remediation strategies.⁹

In Mr. F’s case, such testing was not performed, in part because of his improvement. The MoCA was chosen because it is a universally accepted brief cognitive assessment tool used for screening. More robust testing can be administered by the neuropsychiatry team if indicated and if resources are available.

CASE Sleepless, hallucinating

Mr. F, age 30, is brought to the emergency department (ED) by his brother, with whom he has been living for the last 2 days; his brother says that Mr. F’s wife is afraid of her husband and concerned about her children’s safety. Mr. F has been talking to himself, saying “odd things,” and has an unpredictable temper. He claims that his long-deceased father is alive and telling him “to move to a land that he brought [sic] for him.” In order to follow his father’s instructions, Mr. F says he wants to “see the ambassador so he can get his passport ready.” He also believes his wife and children are intruders in his home. Although he had never smoked before, Mr. F has started smoking ≥2 packs of cigarettes per day, sometimes smoking a pack in 30 minutes. He has not eaten or slept for the last 2 days and lies awake in bed all night staring at the ceiling and smiling to himself.

On examination, Mr. F is short with a slight build and has large, dark eyes, disheveled, short, brown hair, and a scraggly beard. English is not his first language, and he speaks with a thick Eastern European accent. His speech is latent, monotonous, tangential, and illogical. He is alert, oriented only to his person, and says he is 21 or 27 years old and at the hospital for “smoking medication and that’s it.” Despite immigrating to the United States 8 years ago, Mr. F claims he has spent his whole life “here,” although he is unsure of exactly where that is. Cognition and memory are impaired. Regarding his wife and 5 children, he says, “I am a virgin. How then can I have children? That woman is abusing me by forcefully entering my house with 5 kids.” He is fidgety, appears anxious, and does not make eye contact with the examiner during the interview. He is suspicious and irritable. Initial medical workup in the ED is negative.

[polldaddy:9813268]

EVALUATION Labs and observation

Because Mr. F had delusions and hallucinations for the past 2 days and the initial medical workup was negative, brief psychotic disorder is suspected.¹ He is admitted to a secure psychiatric floor for further evaluation. He has no documented medical history. A thorough medical workup for a cause of his hallucinations and delusions, including EEG and brain MRI, is negative. Additional collateral interviews with Mr. F’s wife and brother at a family meeting indicate Mr. F had a slow onset of symptoms that began 4 to 5 years ago. Initially, he became isolated, withdrawn, inactive, and had poor sleep. Recently, he also had become suspicious, irritable, delusional, and hallucinatory. Mr. F used to work full-time in construction, then began working intermittently in a warehouse as a day laborer, but has not worked for the last few months. He used to be an involved father and reliable partner, helping with household chores and caring for the children. However, for the last few months, he had become increasingly apathetic and isolated.

During the comprehensive workup for psychosis, Mr. F’s symptoms continue. He is disoriented; although it is 2015, he states it is “2007… I carry a cell phone so I don’t need to know.” On July 31, he is told the date, and for several days after that, he states that it is July 31. When asked his birth date, he looks at his hospital wrist ID. His affect is flat, but he states he feels “fine” and smiles at inappropriate times. He answers open-ended questions briefly, with irrelevant or illogical answers after long pauses, or not at all. His eye contact is poor; he seems preoccupied with internal stimuli, and it is difficult to keep his attention.
 

Mr. F says he is a “natural-born Bosnian gypsy translator,” and that he needs to finish “building the warehouse” with his father and grandfather (both are deceased). The nurses note that he is withdrawn, inactive, and suspicious; he spends most of the day lying in bed awake, and in the evening he paces in the hallway. Mr. F does not interact with other patients, is guarded when questioned, and does not eat much. He has minimal insight into his condition and says that he is at the hospital for “fevers and a cold,” “ESL treatment,” or because his “right side is thicker” than his left. It is unclear what Mr. F means by “ESL.” It may refer to English as a Second Language, given his apparent perseveration regarding his immigration status and language ability, but this is speculation.

[polldaddy:9813271]

TREATMENT Residual symptoms

With the additional collateral history and a negative medical workup, Mr. F meets DSM-5 criteria for acute, first-episode schizophrenia¹ and is started on risperidone, 2 mg/d, titrated up to 2 mg twice daily, and trazodone, 50 mg, as needed, as a sleep aid. He shows significant improvement in his symptoms early in his treatment course. During visiting hours and at family meetings, he recognizes his wife, and during interviews he denies any continuing hallucinations. He initially says that he never failed to recognize his wife and kids, but later explains that he “woke up different…from a dream, and she was a different woman.” When asked specifically about hearing his father’s voice, he is uncertain, saying “No,” “I don’t know,” “I didn’t hear,” or “Not anymore.”

Despite his improvement, Mr. F continues to be disoriented and suspicious, and has minimal insight into his illness. He also continues to exhibit significant negative symptoms and cognitive impairment. Mr. F is withdrawn and has a flat affect, poverty of speech, delayed processing, and poor focus and attention.

On hospital Day 6, Mr. F reports feeling depressed. He misses his children and wants to go home. He has lost several pounds because he had a poor appetite and is now underweight. He is apathetic; interactions with staff and patients are minimal, he declines to attend group therapy sessions, and he still spends most of his time lying in bed awake or pacing the hallway. He also expresses a desire to quit smoking.

[polldaddy:9813273]

The authors’ observations

Despite its lack of specific inclusion in the DSM-5 criteria,¹ cognitive impairment is a distinct, core, and nearly universal feature of schizophrenia. As demonstrated by Mr. F’s case, the severity of cognitive impairment in schizophrenia has no association with the positive symptoms of schizophrenia; it is a patient’s neuro­cognitive abilities—not the severity of his (her) psychotic symptoms—that most strongly predict functional outcomes.²

Neurocognitive impairment is a strong contributor to and predictor of disability in schizophrenia.^3,4 Treatment of the cognitive symptoms of schizophrenia with antipsychotics has been largely ineffective.² Effective drug therapy regimens are still being developed, and although there are some promising novel targets, no drug is FDA-approved to treat the cognitive symptoms of schizophrenia.^2,4 However, it is known that additional treatment modalities, including social skills training and/or vocational rehabilitation, as well as treatment of comorbid conditions, may lead to improved cognitive status and, as a result, improved functional outcomes in schizophrenia.^2-4

It is well documented that persons with schizophrenia in households with high expressed emotion (EE) have higher rates of relapse, independent of demographics and pharmacotherapy.⁵ EE is a measure of the family environment that evaluates how the relatives of a psychiatric patient spontaneously talk about the patient. Relatives are considered to have high EE if they show hostility or marked emotional overinvolvement, or if they make a certain number of critical comments. The tool used to measure EE is the Camberwell Family Interview Schedule.^6,7 Rates of first-year relapse in high EE homes when family treatment is employed drop significantly, especially when combined with social skills training.⁸ The patient’s family members are educated about EE and its potential negative effects on the patient.

Cognitive remediation therapy (CRT) uses therapist-led, computer-based techniques to preserve intact neuroplasticity and has been shown to improve cognition and functional status, especially when paired with vocational rehabilitation or social skills training.^2,3 Many trials confirm that CRT produces meaningful, durable improvements in cognition and functioning.³ One systematic review that focused on trials in early schizophrenia found that CRT had a significant effect on functioning and symptoms, and that these effects were larger when CRT was combined with adjunctive psychiatric rehabilitation and small group interventions.³

OUTCOME Gradual improvement

Mr. F is started on nicotine gum, 2 mg/d, for smoking cessation and fluoxetine, 20 mg/d, for depression, and a dietary consult is made for his poor appetite and weight loss. His psychotic symptoms continue to improve, and by hospital Day 10, his depressive symptoms begin to improve as well: his affect brightens, he has increased appetite, and he wants to shave. He also exhibits mildly increased insight into his illness.

The authors’ observations

A major goal of the National Institute of Mental Health’s Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative was to develop a consensus cognitive battery for clinical trials of cognition-enhancing treatments for schizophrenia. The MATRICS Consensus Cognitive Battery (MCCB) is a comprehensive cognitive assessment designed for use in patients with schizophrenia (Table 3⁹). Although the MCCB was developed to be the standard tool for assessing cognitive change in clinical trials of cognition-enhancing drugs for schizophrenia, it also may aid evaluation of cognitive remediation strategies.⁹

In Mr. F’s case, such testing was not performed, in part because of his improvement. The MoCA was chosen because it is a universally accepted brief cognitive assessment tool used for screening. More robust testing can be administered by the neuropsychiatry team if indicated and if resources are available.

In response to Dr. Nasrallah’s editorial “Prescribing is the culmination of extensive medical training and psychologists don’t qualify” (From the Editor, Current Psychiatry. June 2017, p. 11-12,14-16): I have mixed feelings about prescription privileges for psychologists, and I am not pursuing them. But Dr. Nasrallah’s manner of arguing with anecdotes and unsubstantiated opinion is undeserving of publication. He notes that psychologists with further training now have prescription privileges in several states and warns of the possible dangers of such practices. However, he did not bother to describe the training psychologists receive or report on the psychiatrists who helped develop that curriculum. Dr. Nasrallah did not present any empirical evidence to indicate that any actual harm has resulted from psychologists having prescription privileges or compare that with the harm from the prescription privileges of psychiatrists, other physicians, physician assistants, nurse practitioners, naturopaths, etc. He implies that only psychiatrists can properly prescribe psychiatric medications, which would certainly be a minority opinion. He offers no alternative solution to the current public health problems.

Tedd Judd, PhD, ABPP-CN
Diplomate in Clinical Neuropsychology
Certified Hispanic Mental Health Specialist
Cross-Cultural Specialist
Bellingham, Washington

I read Dr. Nasrallah’s editorial with a critical eye. As a psychologist in private clinical and forensic practice for more than 30 years, it is disheartening that you toe the politico-economic line proffered over the decades that establishes and buoys a clash between our helping professions in the hoary guise of protecting the consuming public.

It is disingenuous and misleading for you to cite “28,000 hours of training… 8 years of medical school” as a prerequisite for having adequate “psycho­pharmacological skills.”

Psychologists and psychiatrists can learn the same necessary and comprehensive skills to perform competent and equivalent prescription duties in succinct, operational ways.

It is about time the welfare of the consuming public be served instead of territorial profiteering. Perhaps you should focus more on the dwindling numbers of psychiatrists who perform psychotherapy in conjunction with psychopharmacology than on limiting the pool of providers who are qualified by training to do both. How many of those 28,000 hours are dedicated to training your psychiatrists in psychotherapy?

Norman R. Klein, PhD
Licensed Psychologist
Westport, Connecticut

Dr. Nasrallah wrote an unsurprisingly eloquent and passionate editorial and argues a cogent case for restricting prescription privileges to medically trained professionals. I wonder, though, if public health statistics of outcomes among mental health patients in states where clinical psychologists have been licensed to prescribe, such as New Mexico and Hawaii, bear out any of Dr. Nasrallah’s concerns.

Ole J. Thienhaus, MD, MBA
Department Head and Professor of Psychiatry
University of Arizona
College of Medicine-Tucson
Tucson, Arizona
 

Dr. Nasrallah responds

I am not surprised by Dr. Judd’s or Dr. Klein’s disagreement with my editorial asserting that psycho­logists do not receive the medical training that qualifies them to prescribe. They side with their fellow psychologists, just as psychiatrists agree with me. After all, those of us who have had the extensive training of psychiatric physicians know the abundance of medical skills needed for competent prescribing and find it preposterous that psychologists, who have a PhD and are acknowledged for their psychotherapy and psychometric skills, can take a drastic shortcut by getting politicians to give them the right to prescribe. Dr. Klein has no idea how much training it takes to become a competent prescriber, so his comments that both psychiatrists and psych­ologists can be similarly trained cannot be taken seriously. Even after 4 years of psychiatric residency with daily psychopharmacology teaching and training psychiatrists still feel they have much more to learn. It is dangerous hubris to think that even without the vital medical school foundation prior to psychiatric training that psychologists can enroll in a course and practicum and become psychopharmacologists.

Here, I provide a description of one state’s proposed the training that psycho­logists would receive. I hope that Drs. Judd and Klein will recognize the dangerously inadequate training recently proposed for psychologists to become “prescribers.”

Proposed curriculum for psychologists

1. Online instruction, not face-to-face classroom experience

2. Many courses are prerecorded

3. Instructors are psychologists, not psychiatrists

4. Psychologists can complete the program at their own pace, which can be done in a few weeks

5. Hours of instruction range between 306 to 468 hours, compared with 500 hours required for massage therapists

6. A minimum of 40 hours of “basic training on clinical assessment” is required, compared with 60 hours for electrologists

7. The “graduate” must pass a test prepared by the American Psychological Association, which advocates for prescriptive authority and is not an independent testing organization

8. There is no minimum of requirements of an undergraduate biomedical prerequisite course—the work that is required for all medical students, physician assistants, and nursing students—which includes chemistry or biochemistry (with laboratory experience), human anatomy, physiology, general biology, microbiology (with laboratory experience), cell biology, and molecular biology

9. Recommended number of patient encounters is anemic: 600 encounters, which can be 10 encounters with 60 patients or 15 encounters with 40 patients. This is far below what is required of psychiatric residents

10. The proposed training requires treating a minimum of 75 patients over 2 years. A typical third-year psychiatric resident sees 75 patients every month. Each first- and second-year resident works up and treats >600 inpatients in <1 year

11. At the end of the practicum, applicants must demonstrate competency in 9 milestones, but competency is not defined. In contrast, psychiatric residency programs have mandates from the Accreditation Council for Graduate Medical Education requiring that residents be graded every 6 months on 23 milestones, with specific anchor points provided

12. Only 25% of the practicum occurs on psychiatric inpatient wards or outpatient clinics. One wonders where the patients who need psychopharmacology would be

13. Supervision is inadequate. There is no requirement for supervision by psychiatrists, whose training and experience make them qualified psychopharmacologists

14. There is no guidance on the frequency or intensity of supervision. In psychiatry, residents are supervised with each patient encounter over 4 years. Should psychologists without medical training be held to a lesser standard?

15. There are no specifications of continuing medical education, ongoing supervision, or outcomes

16. The potential dangers of psycho­tropics are not emphasized. For example:

• permanent or life-threatening adverse effects, such as tardive dyskinesia or agranulocytosis
• addiction potential, such as with stimulants or benzodiazepines
• potentially fatal drug interactions with monoamine oxidase inhibitors and meperidine or serotonin syndrome, or cardiac arrests with overdoses of tricyclic antidepressants

17. Many medications require on­going monitoring. Some involve physical examination (extrapyramidal side effects, metabolic syndrome) or laboratory tests (lithium, carbamazepine, clozapine, valproate, renal and hepatic functions, metabolic profile for all antipsychotics). Failure to monitor may lead to fatal outcomes. Some medications are considered unsafe during pregnancy or breast-feeding.

Psychologists do a great service for patients with mental illness by providing evidence-based psycho­therapies, such as cognitive-behavioral, dialectical-behavioral, interpersonal, and behavioral therapy. They complement what psychiatrists and nurse practitioners do with pharmaco­therapy. Many patients with mild or moderate psychiatric disorders improve significantly with psychotherapy without the use of psychotropics. Psychologists should focus on what they were trained to do because they can benefit numerous patients. That is much better than trying to become prescribers and practice mediocre psychopharmacology without the requisite medical training. Patients with mental illness deserve no less.
 

Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri

In response to Dr. Nasrallah’s editorial “Prescribing is the culmination of extensive medical training and psychologists don’t qualify” (From the Editor, Current Psychiatry. June 2017, p. 11-12,14-16): I have mixed feelings about prescription privileges for psychologists, and I am not pursuing them. But Dr. Nasrallah’s manner of arguing with anecdotes and unsubstantiated opinion is undeserving of publication. He notes that psychologists with further training now have prescription privileges in several states and warns of the possible dangers of such practices. However, he did not bother to describe the training psychologists receive or report on the psychiatrists who helped develop that curriculum. Dr. Nasrallah did not present any empirical evidence to indicate that any actual harm has resulted from psychologists having prescription privileges or compare that with the harm from the prescription privileges of psychiatrists, other physicians, physician assistants, nurse practitioners, naturopaths, etc. He implies that only psychiatrists can properly prescribe psychiatric medications, which would certainly be a minority opinion. He offers no alternative solution to the current public health problems.

Tedd Judd, PhD, ABPP-CN
Diplomate in Clinical Neuropsychology
Certified Hispanic Mental Health Specialist
Cross-Cultural Specialist
Bellingham, Washington

I read Dr. Nasrallah’s editorial with a critical eye. As a psychologist in private clinical and forensic practice for more than 30 years, it is disheartening that you toe the politico-economic line proffered over the decades that establishes and buoys a clash between our helping professions in the hoary guise of protecting the consuming public.

It is disingenuous and misleading for you to cite “28,000 hours of training… 8 years of medical school” as a prerequisite for having adequate “psycho­pharmacological skills.”

Psychologists and psychiatrists can learn the same necessary and comprehensive skills to perform competent and equivalent prescription duties in succinct, operational ways.

It is about time the welfare of the consuming public be served instead of territorial profiteering. Perhaps you should focus more on the dwindling numbers of psychiatrists who perform psychotherapy in conjunction with psychopharmacology than on limiting the pool of providers who are qualified by training to do both. How many of those 28,000 hours are dedicated to training your psychiatrists in psychotherapy?

Norman R. Klein, PhD
Licensed Psychologist
Westport, Connecticut

Dr. Nasrallah wrote an unsurprisingly eloquent and passionate editorial and argues a cogent case for restricting prescription privileges to medically trained professionals. I wonder, though, if public health statistics of outcomes among mental health patients in states where clinical psychologists have been licensed to prescribe, such as New Mexico and Hawaii, bear out any of Dr. Nasrallah’s concerns.

Ole J. Thienhaus, MD, MBA
Department Head and Professor of Psychiatry
University of Arizona
College of Medicine-Tucson
Tucson, Arizona
 

Dr. Nasrallah responds

I am not surprised by Dr. Judd’s or Dr. Klein’s disagreement with my editorial asserting that psycho­logists do not receive the medical training that qualifies them to prescribe. They side with their fellow psychologists, just as psychiatrists agree with me. After all, those of us who have had the extensive training of psychiatric physicians know the abundance of medical skills needed for competent prescribing and find it preposterous that psychologists, who have a PhD and are acknowledged for their psychotherapy and psychometric skills, can take a drastic shortcut by getting politicians to give them the right to prescribe. Dr. Klein has no idea how much training it takes to become a competent prescriber, so his comments that both psychiatrists and psych­ologists can be similarly trained cannot be taken seriously. Even after 4 years of psychiatric residency with daily psychopharmacology teaching and training psychiatrists still feel they have much more to learn. It is dangerous hubris to think that even without the vital medical school foundation prior to psychiatric training that psychologists can enroll in a course and practicum and become psychopharmacologists.

Here, I provide a description of one state’s proposed the training that psycho­logists would receive. I hope that Drs. Judd and Klein will recognize the dangerously inadequate training recently proposed for psychologists to become “prescribers.”

Proposed curriculum for psychologists

1. Online instruction, not face-to-face classroom experience

2. Many courses are prerecorded

3. Instructors are psychologists, not psychiatrists

4. Psychologists can complete the program at their own pace, which can be done in a few weeks

5. Hours of instruction range between 306 to 468 hours, compared with 500 hours required for massage therapists

6. A minimum of 40 hours of “basic training on clinical assessment” is required, compared with 60 hours for electrologists

7. The “graduate” must pass a test prepared by the American Psychological Association, which advocates for prescriptive authority and is not an independent testing organization

8. There is no minimum of requirements of an undergraduate biomedical prerequisite course—the work that is required for all medical students, physician assistants, and nursing students—which includes chemistry or biochemistry (with laboratory experience), human anatomy, physiology, general biology, microbiology (with laboratory experience), cell biology, and molecular biology

9. Recommended number of patient encounters is anemic: 600 encounters, which can be 10 encounters with 60 patients or 15 encounters with 40 patients. This is far below what is required of psychiatric residents

10. The proposed training requires treating a minimum of 75 patients over 2 years. A typical third-year psychiatric resident sees 75 patients every month. Each first- and second-year resident works up and treats >600 inpatients in <1 year

11. At the end of the practicum, applicants must demonstrate competency in 9 milestones, but competency is not defined. In contrast, psychiatric residency programs have mandates from the Accreditation Council for Graduate Medical Education requiring that residents be graded every 6 months on 23 milestones, with specific anchor points provided

12. Only 25% of the practicum occurs on psychiatric inpatient wards or outpatient clinics. One wonders where the patients who need psychopharmacology would be

13. Supervision is inadequate. There is no requirement for supervision by psychiatrists, whose training and experience make them qualified psychopharmacologists

14. There is no guidance on the frequency or intensity of supervision. In psychiatry, residents are supervised with each patient encounter over 4 years. Should psychologists without medical training be held to a lesser standard?

15. There are no specifications of continuing medical education, ongoing supervision, or outcomes

16. The potential dangers of psycho­tropics are not emphasized. For example:

• permanent or life-threatening adverse effects, such as tardive dyskinesia or agranulocytosis
• addiction potential, such as with stimulants or benzodiazepines
• potentially fatal drug interactions with monoamine oxidase inhibitors and meperidine or serotonin syndrome, or cardiac arrests with overdoses of tricyclic antidepressants

17. Many medications require on­going monitoring. Some involve physical examination (extrapyramidal side effects, metabolic syndrome) or laboratory tests (lithium, carbamazepine, clozapine, valproate, renal and hepatic functions, metabolic profile for all antipsychotics). Failure to monitor may lead to fatal outcomes. Some medications are considered unsafe during pregnancy or breast-feeding.

Psychologists do a great service for patients with mental illness by providing evidence-based psycho­therapies, such as cognitive-behavioral, dialectical-behavioral, interpersonal, and behavioral therapy. They complement what psychiatrists and nurse practitioners do with pharmaco­therapy. Many patients with mild or moderate psychiatric disorders improve significantly with psychotherapy without the use of psychotropics. Psychologists should focus on what they were trained to do because they can benefit numerous patients. That is much better than trying to become prescribers and practice mediocre psychopharmacology without the requisite medical training. Patients with mental illness deserve no less.
 

Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri

In response to Dr. Nasrallah’s editorial “Prescribing is the culmination of extensive medical training and psychologists don’t qualify” (From the Editor, Current Psychiatry. June 2017, p. 11-12,14-16): I have mixed feelings about prescription privileges for psychologists, and I am not pursuing them. But Dr. Nasrallah’s manner of arguing with anecdotes and unsubstantiated opinion is undeserving of publication. He notes that psychologists with further training now have prescription privileges in several states and warns of the possible dangers of such practices. However, he did not bother to describe the training psychologists receive or report on the psychiatrists who helped develop that curriculum. Dr. Nasrallah did not present any empirical evidence to indicate that any actual harm has resulted from psychologists having prescription privileges or compare that with the harm from the prescription privileges of psychiatrists, other physicians, physician assistants, nurse practitioners, naturopaths, etc. He implies that only psychiatrists can properly prescribe psychiatric medications, which would certainly be a minority opinion. He offers no alternative solution to the current public health problems.

Tedd Judd, PhD, ABPP-CN
Diplomate in Clinical Neuropsychology
Certified Hispanic Mental Health Specialist
Cross-Cultural Specialist
Bellingham, Washington

I read Dr. Nasrallah’s editorial with a critical eye. As a psychologist in private clinical and forensic practice for more than 30 years, it is disheartening that you toe the politico-economic line proffered over the decades that establishes and buoys a clash between our helping professions in the hoary guise of protecting the consuming public.

It is disingenuous and misleading for you to cite “28,000 hours of training… 8 years of medical school” as a prerequisite for having adequate “psycho­pharmacological skills.”

Psychologists and psychiatrists can learn the same necessary and comprehensive skills to perform competent and equivalent prescription duties in succinct, operational ways.

It is about time the welfare of the consuming public be served instead of territorial profiteering. Perhaps you should focus more on the dwindling numbers of psychiatrists who perform psychotherapy in conjunction with psychopharmacology than on limiting the pool of providers who are qualified by training to do both. How many of those 28,000 hours are dedicated to training your psychiatrists in psychotherapy?

Norman R. Klein, PhD
Licensed Psychologist
Westport, Connecticut

Dr. Nasrallah wrote an unsurprisingly eloquent and passionate editorial and argues a cogent case for restricting prescription privileges to medically trained professionals. I wonder, though, if public health statistics of outcomes among mental health patients in states where clinical psychologists have been licensed to prescribe, such as New Mexico and Hawaii, bear out any of Dr. Nasrallah’s concerns.

Ole J. Thienhaus, MD, MBA
Department Head and Professor of Psychiatry
University of Arizona
College of Medicine-Tucson
Tucson, Arizona
 

Dr. Nasrallah responds

I am not surprised by Dr. Judd’s or Dr. Klein’s disagreement with my editorial asserting that psycho­logists do not receive the medical training that qualifies them to prescribe. They side with their fellow psychologists, just as psychiatrists agree with me. After all, those of us who have had the extensive training of psychiatric physicians know the abundance of medical skills needed for competent prescribing and find it preposterous that psychologists, who have a PhD and are acknowledged for their psychotherapy and psychometric skills, can take a drastic shortcut by getting politicians to give them the right to prescribe. Dr. Klein has no idea how much training it takes to become a competent prescriber, so his comments that both psychiatrists and psych­ologists can be similarly trained cannot be taken seriously. Even after 4 years of psychiatric residency with daily psychopharmacology teaching and training psychiatrists still feel they have much more to learn. It is dangerous hubris to think that even without the vital medical school foundation prior to psychiatric training that psychologists can enroll in a course and practicum and become psychopharmacologists.

Here, I provide a description of one state’s proposed the training that psycho­logists would receive. I hope that Drs. Judd and Klein will recognize the dangerously inadequate training recently proposed for psychologists to become “prescribers.”

Proposed curriculum for psychologists

1. Online instruction, not face-to-face classroom experience

2. Many courses are prerecorded

3. Instructors are psychologists, not psychiatrists

4. Psychologists can complete the program at their own pace, which can be done in a few weeks

5. Hours of instruction range between 306 to 468 hours, compared with 500 hours required for massage therapists

6. A minimum of 40 hours of “basic training on clinical assessment” is required, compared with 60 hours for electrologists

7. The “graduate” must pass a test prepared by the American Psychological Association, which advocates for prescriptive authority and is not an independent testing organization

8. There is no minimum of requirements of an undergraduate biomedical prerequisite course—the work that is required for all medical students, physician assistants, and nursing students—which includes chemistry or biochemistry (with laboratory experience), human anatomy, physiology, general biology, microbiology (with laboratory experience), cell biology, and molecular biology

9. Recommended number of patient encounters is anemic: 600 encounters, which can be 10 encounters with 60 patients or 15 encounters with 40 patients. This is far below what is required of psychiatric residents

10. The proposed training requires treating a minimum of 75 patients over 2 years. A typical third-year psychiatric resident sees 75 patients every month. Each first- and second-year resident works up and treats >600 inpatients in <1 year

11. At the end of the practicum, applicants must demonstrate competency in 9 milestones, but competency is not defined. In contrast, psychiatric residency programs have mandates from the Accreditation Council for Graduate Medical Education requiring that residents be graded every 6 months on 23 milestones, with specific anchor points provided

12. Only 25% of the practicum occurs on psychiatric inpatient wards or outpatient clinics. One wonders where the patients who need psychopharmacology would be

13. Supervision is inadequate. There is no requirement for supervision by psychiatrists, whose training and experience make them qualified psychopharmacologists

14. There is no guidance on the frequency or intensity of supervision. In psychiatry, residents are supervised with each patient encounter over 4 years. Should psychologists without medical training be held to a lesser standard?

15. There are no specifications of continuing medical education, ongoing supervision, or outcomes

16. The potential dangers of psycho­tropics are not emphasized. For example:

• permanent or life-threatening adverse effects, such as tardive dyskinesia or agranulocytosis
• addiction potential, such as with stimulants or benzodiazepines
• potentially fatal drug interactions with monoamine oxidase inhibitors and meperidine or serotonin syndrome, or cardiac arrests with overdoses of tricyclic antidepressants

17. Many medications require on­going monitoring. Some involve physical examination (extrapyramidal side effects, metabolic syndrome) or laboratory tests (lithium, carbamazepine, clozapine, valproate, renal and hepatic functions, metabolic profile for all antipsychotics). Failure to monitor may lead to fatal outcomes. Some medications are considered unsafe during pregnancy or breast-feeding.

Psychologists do a great service for patients with mental illness by providing evidence-based psycho­therapies, such as cognitive-behavioral, dialectical-behavioral, interpersonal, and behavioral therapy. They complement what psychiatrists and nurse practitioners do with pharmaco­therapy. Many patients with mild or moderate psychiatric disorders improve significantly with psychotherapy without the use of psychotropics. Psychologists should focus on what they were trained to do because they can benefit numerous patients. That is much better than trying to become prescribers and practice mediocre psychopharmacology without the requisite medical training. Patients with mental illness deserve no less.
 

Henry A. Nasrallah, MD
Professor and Chair
Department of Psychiatry and Behavioral Neuroscience
Saint Louis University School of Medicine
St. Louis, Missouri

Second-generation antipsychotics (SGAs) have been a remarkably effective innovation in psychotropic therapy. Unfortunately, the metabolic effects of these medications—primarily weight gain—present an obstacle to medication adherence. Preliminary studies have suggested that melatonin, a hormone most commonly used as a sleep aid, may help minimize weight gain among patients receiving SGAs.

Modabbernia et al¹ demonstrated positive results from melatonin augmentation in an 8-week, randomized, double-blind, placebo-controlled study of 48 patients with first-episode schizophrenia. Compared with patients who received olanzapine and placebo, those taking olanzapine and melatonin, 3 mg/d, had significantly less weight gain, smaller increases in abdominal obesity, and lower triglycerides. Patients who were given melatonin also had a significantly greater reduction on the Positive and Negative Symptom Scale score.¹

Romo-Nava et al² had similar findings in an 8-week, randomized, double-blind, placebo-controlled trial. Forty-four patients (24 with schizophrenia, 20 with bipolar disorder) who were taking clozapine, quetiapine, risperidone, or olanzapine received adjunctive melatonin, 5 mg/d, or placebo. Patients receiving melatonin had significantly less weight gain (P = .04) and significantly reduced diastolic blood pressure (5.1 vs 1.1 mm Hg; P = .03).

In both studies, researchers hypo­thesized that melatonin exerted its effect through the suprachiasmatic nucleus—the part of the hypothalamus that regulates body weight, energy balance, and meta­bolism. Exogenous melatonin suppresses intra-abdominal fat and restores serum leptin and insulin levels in middle-aged rats, partly due to correcting the age-related decline in melatonin production.³

Wang et al⁴ conducted a systematic review of using melatonin in patients taking SGAs. In addition to preventing metabolic adverse effects of antipsychotics, melatonin also reduced weight gain from lithium.

Early evidence suggests that this in­expensive and relatively safe augmenting agent can minimize metabolic effects of SGAs. It is surprising that scheduled melatonin has eluded popular use in psychiatry.

Second-generation antipsychotics (SGAs) have been a remarkably effective innovation in psychotropic therapy. Unfortunately, the metabolic effects of these medications—primarily weight gain—present an obstacle to medication adherence. Preliminary studies have suggested that melatonin, a hormone most commonly used as a sleep aid, may help minimize weight gain among patients receiving SGAs.

Modabbernia et al¹ demonstrated positive results from melatonin augmentation in an 8-week, randomized, double-blind, placebo-controlled study of 48 patients with first-episode schizophrenia. Compared with patients who received olanzapine and placebo, those taking olanzapine and melatonin, 3 mg/d, had significantly less weight gain, smaller increases in abdominal obesity, and lower triglycerides. Patients who were given melatonin also had a significantly greater reduction on the Positive and Negative Symptom Scale score.¹

Romo-Nava et al² had similar findings in an 8-week, randomized, double-blind, placebo-controlled trial. Forty-four patients (24 with schizophrenia, 20 with bipolar disorder) who were taking clozapine, quetiapine, risperidone, or olanzapine received adjunctive melatonin, 5 mg/d, or placebo. Patients receiving melatonin had significantly less weight gain (P = .04) and significantly reduced diastolic blood pressure (5.1 vs 1.1 mm Hg; P = .03).

In both studies, researchers hypo­thesized that melatonin exerted its effect through the suprachiasmatic nucleus—the part of the hypothalamus that regulates body weight, energy balance, and meta­bolism. Exogenous melatonin suppresses intra-abdominal fat and restores serum leptin and insulin levels in middle-aged rats, partly due to correcting the age-related decline in melatonin production.³

Wang et al⁴ conducted a systematic review of using melatonin in patients taking SGAs. In addition to preventing metabolic adverse effects of antipsychotics, melatonin also reduced weight gain from lithium.

Early evidence suggests that this in­expensive and relatively safe augmenting agent can minimize metabolic effects of SGAs. It is surprising that scheduled melatonin has eluded popular use in psychiatry.

Second-generation antipsychotics (SGAs) have been a remarkably effective innovation in psychotropic therapy. Unfortunately, the metabolic effects of these medications—primarily weight gain—present an obstacle to medication adherence. Preliminary studies have suggested that melatonin, a hormone most commonly used as a sleep aid, may help minimize weight gain among patients receiving SGAs.

Modabbernia et al¹ demonstrated positive results from melatonin augmentation in an 8-week, randomized, double-blind, placebo-controlled study of 48 patients with first-episode schizophrenia. Compared with patients who received olanzapine and placebo, those taking olanzapine and melatonin, 3 mg/d, had significantly less weight gain, smaller increases in abdominal obesity, and lower triglycerides. Patients who were given melatonin also had a significantly greater reduction on the Positive and Negative Symptom Scale score.¹

Romo-Nava et al² had similar findings in an 8-week, randomized, double-blind, placebo-controlled trial. Forty-four patients (24 with schizophrenia, 20 with bipolar disorder) who were taking clozapine, quetiapine, risperidone, or olanzapine received adjunctive melatonin, 5 mg/d, or placebo. Patients receiving melatonin had significantly less weight gain (P = .04) and significantly reduced diastolic blood pressure (5.1 vs 1.1 mm Hg; P = .03).

In both studies, researchers hypo­thesized that melatonin exerted its effect through the suprachiasmatic nucleus—the part of the hypothalamus that regulates body weight, energy balance, and meta­bolism. Exogenous melatonin suppresses intra-abdominal fat and restores serum leptin and insulin levels in middle-aged rats, partly due to correcting the age-related decline in melatonin production.³

Wang et al⁴ conducted a systematic review of using melatonin in patients taking SGAs. In addition to preventing metabolic adverse effects of antipsychotics, melatonin also reduced weight gain from lithium.

Early evidence suggests that this in­expensive and relatively safe augmenting agent can minimize metabolic effects of SGAs. It is surprising that scheduled melatonin has eluded popular use in psychiatry.

Use of α-pyrrolidinovalerophenone (α-PVP), a psychostimulant related to cathinone derivatives (“bath salts”), has been reported in the United States, especially in Florida.¹ Known by the street names “flakka” or “gravel,” α-PVP is inexpensive, with a single dose (typically 100 mg) costing as little as $5.² Alpha-PVP can be consumed via ingestion, injection, insufflation, or inhalation in vaporized forms, such as E-cigarettes, which deliver the drug quickly into the bloodstream and can make it easy to overdose.¹ The low cost of this drug makes it likely to be abused. Here we review the mechanism of action and effects of α-PVP and summarize treatment options.

Mechanism of action

Alpha-PVP is a structural parent of 3,4-methylenedioxypyrovalerone (MDPV)—the first widely abused synthetic cathinone.³ Much like cocaine, α-PVP stimulates the CNS by acting as a potent dopamine and norepinephrine reuptake inhibitor. However, unlike cocaine, it lacks any action on serotonin transporters. The pyrrolidine ring in MDPV and α-PVP is responsible for the highly potent dopamine reuptake inhibitor action of these agents.³

A wide range of adverse effects

Use of α-PVP results in a state of “excited delirium,” with symptoms such as hyperthermia, hallucinations, paranoia, violent aggression, and self-harm.¹ Alpha-PVP is known to cause rhabdomyolysis.⁴ Some studies have reported cardiovascular effects, such as arterial hypertension, palpitations, dyspnea, vasoconstriction, arrhythmia, myocardial infarction (MI), and myocarditis.⁵ Alpha-PVP also may result in neurologic symptoms, including headache, mydriasis, lightheadedness, paresthesia, seizures, dystonic movements, tremor, amnesia, dysgeusia, cerebral edema, motor automatisms, muscle spasm, nystagmus, parkinsonism, and stroke.⁵ Death may occur by cardiac arrest, renal damage, or suicide.

Case reports. The effects of α-PVP have been documented in the literature:

• A 17-year-old girl was brought to an emergency department in Florida with acute onset of bizarre behavior, agitation, and altered mental status. It took 6 days and repeated administrations of olanzapine and lorazepam for the patient to become calm, alert, and oriented.²
• ST-elevated MI with several intracardiac thrombi was reported in a 41-year-old woman who used α-PVP.⁴
• In 2015, 18 deaths related to α-PVP use were reported in South Florida.⁵
• Deaths related to α-PVP use also have been reported in Japan and Australia.⁵

Treatment options

There are no treatment guidelines for α-PVP-related psychiatric symptoms. Case reports describe remission of symptoms following aggressive treatment with antipsychotics and benzodiazepines.² Guidelines for treatment of stimulant-induced behavioral and psychotic symptoms⁶ may be considered for patients who have used α-PVP.

Reassurance and supportive care are the basic principles of such interventions. A quiet environment and benzo­diazepines may provide relief of agitation. Antipsychotics may be helpful if a patient exhibits psychotic symptoms.

Similar drugs may emerge

In 2014, the DEA classified α-PVP as a Schedule I substance. Laws against the import of such substances via the Internet or other means also may help control the spread of this drug. However, chemically similar drugs that may elude drug screens are continually emerging. The lack of evidence-based guidelines on recognizing and managing intoxication, withdrawal, and long-term effects of α-PVP and other “designer drugs” calls for greater research in this emerging area of substance use disorders.

Use of α-pyrrolidinovalerophenone (α-PVP), a psychostimulant related to cathinone derivatives (“bath salts”), has been reported in the United States, especially in Florida.¹ Known by the street names “flakka” or “gravel,” α-PVP is inexpensive, with a single dose (typically 100 mg) costing as little as $5.² Alpha-PVP can be consumed via ingestion, injection, insufflation, or inhalation in vaporized forms, such as E-cigarettes, which deliver the drug quickly into the bloodstream and can make it easy to overdose.¹ The low cost of this drug makes it likely to be abused. Here we review the mechanism of action and effects of α-PVP and summarize treatment options.

Mechanism of action

Alpha-PVP is a structural parent of 3,4-methylenedioxypyrovalerone (MDPV)—the first widely abused synthetic cathinone.³ Much like cocaine, α-PVP stimulates the CNS by acting as a potent dopamine and norepinephrine reuptake inhibitor. However, unlike cocaine, it lacks any action on serotonin transporters. The pyrrolidine ring in MDPV and α-PVP is responsible for the highly potent dopamine reuptake inhibitor action of these agents.³

A wide range of adverse effects

Use of α-PVP results in a state of “excited delirium,” with symptoms such as hyperthermia, hallucinations, paranoia, violent aggression, and self-harm.¹ Alpha-PVP is known to cause rhabdomyolysis.⁴ Some studies have reported cardiovascular effects, such as arterial hypertension, palpitations, dyspnea, vasoconstriction, arrhythmia, myocardial infarction (MI), and myocarditis.⁵ Alpha-PVP also may result in neurologic symptoms, including headache, mydriasis, lightheadedness, paresthesia, seizures, dystonic movements, tremor, amnesia, dysgeusia, cerebral edema, motor automatisms, muscle spasm, nystagmus, parkinsonism, and stroke.⁵ Death may occur by cardiac arrest, renal damage, or suicide.

Case reports. The effects of α-PVP have been documented in the literature:

• A 17-year-old girl was brought to an emergency department in Florida with acute onset of bizarre behavior, agitation, and altered mental status. It took 6 days and repeated administrations of olanzapine and lorazepam for the patient to become calm, alert, and oriented.²
• ST-elevated MI with several intracardiac thrombi was reported in a 41-year-old woman who used α-PVP.⁴
• In 2015, 18 deaths related to α-PVP use were reported in South Florida.⁵
• Deaths related to α-PVP use also have been reported in Japan and Australia.⁵

Treatment options

There are no treatment guidelines for α-PVP-related psychiatric symptoms. Case reports describe remission of symptoms following aggressive treatment with antipsychotics and benzodiazepines.² Guidelines for treatment of stimulant-induced behavioral and psychotic symptoms⁶ may be considered for patients who have used α-PVP.

Reassurance and supportive care are the basic principles of such interventions. A quiet environment and benzo­diazepines may provide relief of agitation. Antipsychotics may be helpful if a patient exhibits psychotic symptoms.

Similar drugs may emerge

In 2014, the DEA classified α-PVP as a Schedule I substance. Laws against the import of such substances via the Internet or other means also may help control the spread of this drug. However, chemically similar drugs that may elude drug screens are continually emerging. The lack of evidence-based guidelines on recognizing and managing intoxication, withdrawal, and long-term effects of α-PVP and other “designer drugs” calls for greater research in this emerging area of substance use disorders.

Use of α-pyrrolidinovalerophenone (α-PVP), a psychostimulant related to cathinone derivatives (“bath salts”), has been reported in the United States, especially in Florida.¹ Known by the street names “flakka” or “gravel,” α-PVP is inexpensive, with a single dose (typically 100 mg) costing as little as $5.² Alpha-PVP can be consumed via ingestion, injection, insufflation, or inhalation in vaporized forms, such as E-cigarettes, which deliver the drug quickly into the bloodstream and can make it easy to overdose.¹ The low cost of this drug makes it likely to be abused. Here we review the mechanism of action and effects of α-PVP and summarize treatment options.

Mechanism of action

Alpha-PVP is a structural parent of 3,4-methylenedioxypyrovalerone (MDPV)—the first widely abused synthetic cathinone.³ Much like cocaine, α-PVP stimulates the CNS by acting as a potent dopamine and norepinephrine reuptake inhibitor. However, unlike cocaine, it lacks any action on serotonin transporters. The pyrrolidine ring in MDPV and α-PVP is responsible for the highly potent dopamine reuptake inhibitor action of these agents.³

A wide range of adverse effects

Use of α-PVP results in a state of “excited delirium,” with symptoms such as hyperthermia, hallucinations, paranoia, violent aggression, and self-harm.¹ Alpha-PVP is known to cause rhabdomyolysis.⁴ Some studies have reported cardiovascular effects, such as arterial hypertension, palpitations, dyspnea, vasoconstriction, arrhythmia, myocardial infarction (MI), and myocarditis.⁵ Alpha-PVP also may result in neurologic symptoms, including headache, mydriasis, lightheadedness, paresthesia, seizures, dystonic movements, tremor, amnesia, dysgeusia, cerebral edema, motor automatisms, muscle spasm, nystagmus, parkinsonism, and stroke.⁵ Death may occur by cardiac arrest, renal damage, or suicide.

Case reports. The effects of α-PVP have been documented in the literature:

• A 17-year-old girl was brought to an emergency department in Florida with acute onset of bizarre behavior, agitation, and altered mental status. It took 6 days and repeated administrations of olanzapine and lorazepam for the patient to become calm, alert, and oriented.²
• ST-elevated MI with several intracardiac thrombi was reported in a 41-year-old woman who used α-PVP.⁴
• In 2015, 18 deaths related to α-PVP use were reported in South Florida.⁵
• Deaths related to α-PVP use also have been reported in Japan and Australia.⁵

Treatment options

There are no treatment guidelines for α-PVP-related psychiatric symptoms. Case reports describe remission of symptoms following aggressive treatment with antipsychotics and benzodiazepines.² Guidelines for treatment of stimulant-induced behavioral and psychotic symptoms⁶ may be considered for patients who have used α-PVP.

Reassurance and supportive care are the basic principles of such interventions. A quiet environment and benzo­diazepines may provide relief of agitation. Antipsychotics may be helpful if a patient exhibits psychotic symptoms.

Similar drugs may emerge

In 2014, the DEA classified α-PVP as a Schedule I substance. Laws against the import of such substances via the Internet or other means also may help control the spread of this drug. However, chemically similar drugs that may elude drug screens are continually emerging. The lack of evidence-based guidelines on recognizing and managing intoxication, withdrawal, and long-term effects of α-PVP and other “designer drugs” calls for greater research in this emerging area of substance use disorders.

As psychiatrists, we do not often encounter situations in which we need to inform patients and their families that they have a life-threatening diagnosis. Nonetheless, on the rare occasions when we work with such patients, new psychiatrists may find their clinical skills challenged. Breaking bad news remains an aspect of clinical training that is often overlooked by medical schools.

Here I present a case that illustrates the challenges residents and medical students face when they need to deliver bad news and review the current literature on how to present patients with this type of information.

Case
Bizarre behavior, difficult diagnosis

Mr. C, age 59, with a 1-year history of major depressive disorder, was brought to the emergency department by his wife for worsening depression and disorganized behavior over the course of 3 weeks. Mr. C had obsessive thoughts about arranging things in symmetrical patterns, difficulty sleeping, loss of appetite, and anhedonia. His wife reported that his bizarre, disorganized behavior further intensified in the previous week; he was urinating on the rug, rubbing his genitals against the bathroom counter, staring into space without moving for prolonged periods of time, and arranging his food in symmetrical patterns. Mr. C has no reported substance use or suicidal or homicidal ideation.

Strategies for delivering bad news

Initially, I struggled when I realized I would have to deliver the news of this potentially life-threatening diagnosis to the patient and his wife because I had not received any training on how to do so. However, I took time to look into the literature and used the skills that we as psychiatrists have, including empathy, listening, and validation. My experience with Mr. C and his family made me realize that delivering bad news with empathy and being involved in the struggle that follows can make a significant difference to their suffering.

There are various models and techniques for breaking bad news to patients. Two of the most commonly used models in the oncology setting are the SPIKES (Set up, Perception, Interview, Knowledge, Emotions, Strategize and Summarize) model (Table 1²) and Kaye’s model (Table 2³).

• Choose a setting with adequate privacy, use simple language that distills medical facts into appreciable pieces of information, and give the recipients ample space and time to process the implications. Doing so will foster better understanding and facilitate their acceptance of the bad news.
• Although physicians can rarely appreciate the patient’s feelings at a personal level, make every effort to validate their thoughts and offer emotional support. In such situations, it is often appropriate to move closer to the recipient and make brief physical gestures, such as laying a hand on the shoulder, which might comfort them.
• In the aftermath of such encounters, it is important to remain active in the patient’s emotional journey and available for further clarification, which can mitigate uncertainties and facilitate the difficult process of coming to terms with new realities.^4,5

As psychiatrists, we do not often encounter situations in which we need to inform patients and their families that they have a life-threatening diagnosis. Nonetheless, on the rare occasions when we work with such patients, new psychiatrists may find their clinical skills challenged. Breaking bad news remains an aspect of clinical training that is often overlooked by medical schools.

Here I present a case that illustrates the challenges residents and medical students face when they need to deliver bad news and review the current literature on how to present patients with this type of information.

Case
Bizarre behavior, difficult diagnosis

Mr. C, age 59, with a 1-year history of major depressive disorder, was brought to the emergency department by his wife for worsening depression and disorganized behavior over the course of 3 weeks. Mr. C had obsessive thoughts about arranging things in symmetrical patterns, difficulty sleeping, loss of appetite, and anhedonia. His wife reported that his bizarre, disorganized behavior further intensified in the previous week; he was urinating on the rug, rubbing his genitals against the bathroom counter, staring into space without moving for prolonged periods of time, and arranging his food in symmetrical patterns. Mr. C has no reported substance use or suicidal or homicidal ideation.

Strategies for delivering bad news

Initially, I struggled when I realized I would have to deliver the news of this potentially life-threatening diagnosis to the patient and his wife because I had not received any training on how to do so. However, I took time to look into the literature and used the skills that we as psychiatrists have, including empathy, listening, and validation. My experience with Mr. C and his family made me realize that delivering bad news with empathy and being involved in the struggle that follows can make a significant difference to their suffering.

There are various models and techniques for breaking bad news to patients. Two of the most commonly used models in the oncology setting are the SPIKES (Set up, Perception, Interview, Knowledge, Emotions, Strategize and Summarize) model (Table 1²) and Kaye’s model (Table 2³).

• Choose a setting with adequate privacy, use simple language that distills medical facts into appreciable pieces of information, and give the recipients ample space and time to process the implications. Doing so will foster better understanding and facilitate their acceptance of the bad news.
• Although physicians can rarely appreciate the patient’s feelings at a personal level, make every effort to validate their thoughts and offer emotional support. In such situations, it is often appropriate to move closer to the recipient and make brief physical gestures, such as laying a hand on the shoulder, which might comfort them.
• In the aftermath of such encounters, it is important to remain active in the patient’s emotional journey and available for further clarification, which can mitigate uncertainties and facilitate the difficult process of coming to terms with new realities.^4,5

As psychiatrists, we do not often encounter situations in which we need to inform patients and their families that they have a life-threatening diagnosis. Nonetheless, on the rare occasions when we work with such patients, new psychiatrists may find their clinical skills challenged. Breaking bad news remains an aspect of clinical training that is often overlooked by medical schools.

Here I present a case that illustrates the challenges residents and medical students face when they need to deliver bad news and review the current literature on how to present patients with this type of information.

Case
Bizarre behavior, difficult diagnosis

Mr. C, age 59, with a 1-year history of major depressive disorder, was brought to the emergency department by his wife for worsening depression and disorganized behavior over the course of 3 weeks. Mr. C had obsessive thoughts about arranging things in symmetrical patterns, difficulty sleeping, loss of appetite, and anhedonia. His wife reported that his bizarre, disorganized behavior further intensified in the previous week; he was urinating on the rug, rubbing his genitals against the bathroom counter, staring into space without moving for prolonged periods of time, and arranging his food in symmetrical patterns. Mr. C has no reported substance use or suicidal or homicidal ideation.

Strategies for delivering bad news

Initially, I struggled when I realized I would have to deliver the news of this potentially life-threatening diagnosis to the patient and his wife because I had not received any training on how to do so. However, I took time to look into the literature and used the skills that we as psychiatrists have, including empathy, listening, and validation. My experience with Mr. C and his family made me realize that delivering bad news with empathy and being involved in the struggle that follows can make a significant difference to their suffering.

There are various models and techniques for breaking bad news to patients. Two of the most commonly used models in the oncology setting are the SPIKES (Set up, Perception, Interview, Knowledge, Emotions, Strategize and Summarize) model (Table 1²) and Kaye’s model (Table 2³).

• Choose a setting with adequate privacy, use simple language that distills medical facts into appreciable pieces of information, and give the recipients ample space and time to process the implications. Doing so will foster better understanding and facilitate their acceptance of the bad news.
• Although physicians can rarely appreciate the patient’s feelings at a personal level, make every effort to validate their thoughts and offer emotional support. In such situations, it is often appropriate to move closer to the recipient and make brief physical gestures, such as laying a hand on the shoulder, which might comfort them.
• In the aftermath of such encounters, it is important to remain active in the patient’s emotional journey and available for further clarification, which can mitigate uncertainties and facilitate the difficult process of coming to terms with new realities.^4,5